
Glass. 
Book 



COPYRIGHT DEPOSIT 



DISEASES 



EAR, NOSE, AND THROAT 



THEIR ACCESSORY CAVITIES 



SETH SCOTT BISHOP, M.D., D.C.L., LL.D. 

Professor of Diseases of the Nose, Throat, and Ear in the Illinois Medical College; Professor 

the Chicago Post-graduate Medical School and Hospital: Surgeon to the Post-graduate 

Hospital; Consulting Surgeon to the Mary Thompson Hospital, to the Illinois 

Masonic Orphans' Home, and to the Silver Cross Hospital of Joliet ; 

Formerly Surgeon- to the South-side Free Dispensary and 

to the West-side Free Dispensary; One of the 

Editors of the Laryngoscope, etc. 



Second Edition. Thoroughly Revised and Enlarged 



Illustrated with Ninety=four Colored Lithographs and Two Hundred 
and Sixteen Additional Illustrations 



13 M 



PHILADELPHIA, NEW YORK, CHICAGO 
THE F. A. DAVIS COMPANY, PUBLISHERS 

1898 



1830,8 



.843 



'rid COPY, 
1830. 



COPYRIGHT, 1898, 

BY 

THE F. A. DAVIS COMPANY. 

[Registered at Stationers' Hall, London, Eng.] 



OCT 3 11898 





& of Co^ 



Philadelphia, Pa., U. S. A. 

The Medical Bulletin Printing-House 

1916 Cherry Street. 






N RECOGNITION OF HIS DISTINGUISHED 
SERVICES 



ADVANCEMENT OF SURGERY, 
THIS BOOK 

IS 

Affectionately Dedicated 

TO 

PROF. NICHOLAS SENN, M.D., Ph.D., LL.D., 

BV 

THE AUTHOR. 



PEEFACE TO THE SECOXD EDITTOX. 



The early exhaustion of the first edition lias afforded a welcome 
opportunity to add many desirable improvements in the second. The 
writer is under deep obligations for the cordial reception and generous 
criticism of the book by the medical press and profession. Many of 
the excellent suggestions made by the reviewers, who are largely 
teachers in this branch, have been acted upon, with the result of in- 
corporating new subjects and much other new and valuable material. 

The generally-expressed wish for enlargement and greater detail 
in the treatment of various diseases has been met, as far as could con- 
sistently be done. Two new chapters have been written, one on "Re- 
lated Diseases of the Eye and Xose," and the other on "Life-insurance 
Affected by Diseases of the Ear, Xose, and Throat."' Illustrated 
articles on "Direct Laryngoscopy, or Autoscopy"; and on "Pachy- 
dermia Laryngis,' v etc., have been added. Many new colored drawings 
and half-tone engravings from photographs of interesting and in- 
structive cases, specimens, and preparations have been made for this 
edition. 

It was the original purpose to condense as much indispensable in- 
formation as possible in a book of convenient size for students and 
general practitioners, and it has been found practicable to hold to this 
method ■ while making the additions of new matter, to the extent of 
more than 25 per centum, by utilizing to the highest advantage the 
arts of lithography, engraving, and printing. 

Instead of devoting the usual large space to descriptive anatomy, 
this subject is profusely pictured in close association with the diseases 
treated of, and the many illustrations, together with their accompany- 
ing explanations, keep the various organs, their surgical relations, and 
their varying appearances in health and disease always before the 
eye. It is believed that, with the more extended treatment of the most 
important subjects and their ample illustrations, this volume will meet 
with even a more cordial favor among the specialists than the first 
edition was fortunate enough to enjoy. 

For valuable services in preparing illustrations for the second 
edition the writer desires to express -his acknowledgments and thanks 



VI PKEFACE. 

to Professor Politzer for his permission to reproduce a number of his 
artistic colored figures; to Mr. Beady, the medical artist, for colored 
drawings; to Max Thorner for illustrations of direct laryngoscopy; 
and to E. C. Talbot and C. W. Baker for photographs. 

Moved by the kind welcome accorded to the first edition, the 
writer has earnestly endeavored to make the second issue more fully 
and satisfactorily meet the requirements of a magnanimous profession. 



S. S. B. 



103 State Street, Chicago, 
September 15, 1898. 



PREFACE 



Frequent requests from medical students and general practi- 
tioners for a book on diseases of the ear, nose, and throat especially 
adapted to their needs have prompted the writer to endeavor to meet 
this demand. 

This work was designed, first, to help students in preparing for 
their degree; second, for those progressive practitioners who wish to 
acquire the proficiency necessary to properly treat those patients who 
are unable to visit specialists; and, third, for those who are gradually 
exchanging their general practice for special work in these branches. 

The subjects are simplified and condensed so as to constitute this 
book a key, or introduction, to the exhaustive treatises already in the 
field. The place of the latter is not expected to be filled by this un- 
pretentious book, for it was not intended primarily for specialists. 
Yet it is hoped that it may modestly serve their interests in bringing 
information on the subjects down to the present date, and as a work 
of read}' reference. 

Several subjects are treated in greater detail than characterizes 
the work as a whole, for the following reasons: Xo book, equivalent 
to this, is now available containing the latest developments concern- 
ing diphtheria, the blood-serum therapy, the medical and surgical 
management of mastoid diseases, the related diseases of the eye and 
nose, the most successful treatment of hay fever, the improved com- 
pressed-air instruments, vaporizing apparatus, inhalents, etc. There- 
fore these subjects are given especial prominence. The opinions and 
experiences of a large number of eminent authorities are presented on 
the subjects of diphtheria, antitoxin therapy, and hay fever. 

Like works on general medicine and surgery, little space is de- 
voted to the anatomy of the various organs. It is assumed that the 
reader either has a fair understanding of anatomy or possesses such a 
book for reference. This fact, taken with the use of the descriptive 
illustrations, permits the devotion of most of our pages to diseases and 
their treatment. The new atlas of colored drawings by Professor 
Politzer is recommended as an aid in the study of middle-ear diseases. 

(vii) 



Ylll PKEFACE. 

The writer lias freely consulted many books and journals, and 
desires to fully and frankly acknowledge Ms very great indebtedness 
to them. Chiefly among these are the works of Politzer (Dodd's 
translation), Sajons, Burnett, Gruber, Koosa, Browne, Mackenzie, 
Ingals, Bosworth, Tnttle, the American Year-book, etc. 

For generous contributions of valuable figures and plates I am 
under deep obligations to Politzer, Sajons; Trnax, Greene & Company; 
Holmes, and Krieger; and, for photographing, to F. A. Place. I am 
indebted, also, to my assistant, C. L. Enslee, for the laborious task of 
preparing the statistical table of 15,300 cases from any clinical record- 
books. 

It remains to express my sincere appreciation of the cordial co- 
operation, and the artistic execution of the publishers' important part 
in the work, by The F. A. Davis Company. 

The author indulges the hope that his labor may lighten the 
task of his readers in acquiring an understanding of the subjects 
taught. 

S. S. B. 

103 State Street, Chicago, 
February 7, 1897. 



CONTEXTS. 



PART I. 

DISEASES OE THE EAR. 

CHAPTER I. 

PAGE 

A General Consideration of Diseases of the Ear. Xose. and 
Throat Based ox a Study of Twenty-one Thousand 
Cases 3 

CHAPTER II. 

Examination of Patients 13 

Instruments and apparatus. Tests for hearing. Recording cases. 

CHAPTER III. 

Compressed-Air Appliances and their Uses 29 

Accurate methods of treatment with compressed air. High- and 
low- pressure devices. How to use high pressure safely. The 
advantages of improved air-condensers over rubber bags. De- 
tails of treatment with air- meters, or regulators. 

CHAPTER IV. 

Methods of Producing and Using Compressed Air 36 

The most useful devices for hand- and water- power pressure. 
Politzerization. Catheterization. Auscultation. 

CHAPTER V. 

Diseases of the External Ear 47 

Frost-bite. Eczema. Lupus. Gangrene. Carcinoma. Perichon- 
dritis. Hsematoma. Cystoma. Intertrigo. Herpes. Pemphigus. 
Syphilis. Deformities of the auricle. Hypertrophied auricle. 
Scroll-ear and associated deformities. 

CHAPTER VI. 

Diseases of the External Auditory Canal 5Q 

Inspissated and impacted cerumen. Diffuse inflammation of the 
external meatus. Furunculosis. Parasitic inflammation, or 
otomycosis. Exostoses. Imperforate meatus. Foreign bodies 
in the meatus. 

CHAPTER VII. 

Diseases of the Middle Ear G7 

Injuries of the drum-head. Inflammation of the drum-head. Eu- 
stachian tubal catarrh, or salpingitis. Acute inflammation of the 
middle ear. 

(ix) 



X CONTEXTS. 

CHAPTER VIII. 

PAGE 

Diseases of the Middle Ear, Continued 78 

Acute suppurative inflammation of the middle ear. Chronic non- 
suppurative inflammation of the middle ear. Hypertrophic, or 
secretive, catarrh of the middle ear. 

CHAPTER IX. 

Diseases of the Middle Ear, Continued 90 

Sclerosis, or the adhesive inflammation of the middle ear. 

CHAPTER X. 
Diseases of the Middle Ear, Continued 104 

Operative treatment of tympanic sclerosis. Mobilization of the 
ossicles. Incision of the posterior fold of the drum-head. Mul- 
tiple incisions of the drum-head. Excision of areas of the drum- 
head. Division of the tensor tympani. Excision of the membrana 
tympani and ossicles. Operation for excision of the ossicles. 
Mobilization of the stirrup. Stapedectomy. 

CHAPTER XL 

Diseases of the Middle Ear, Continued 116 

Chronic suppurative inflammation of the middle ear. Aspiration 
of the tympanic cavity. 

CHAPTER XII. 

Diseases of the Middle Ear, Concluded 127 

Sequels of middle-ear inflammation. Granulations. Polypi. Caries 
and necrosis of the tympanic cavity. Necrosis of the ossicles. 
Adhesions, cicatrices, and perforations of the membrana tym- 
pani. Artificial drum-heads. Deafness following suppuration. 
Tinnitus in purulent inflammation. Cholesteatoma. Facial- 
nerve paresis and paralysis. Carious processes in the temporal 
bone. 

CHAPTER XIII. 

Extension of Ear Diseases to the Cranial Cavity 143 

Meningitis. Extradural abscess. Cerebral abscess. Cerebellar ab- 
scess. Operations for brain-abscesses. Sinus-phlebitis and sinus- 
thrombosis. 

CHAPTER XIV. 

Diseases of the Mastoid Process 149 

Medical treatment. Indications and preparations for mastoid 
operations. Preparation of patient. Instruments required. 
Preparation of instruments. 

CHAPTER XV. 

The Mastoid Operations 162 

The Schwartze operation. The radical tympano-mastoid, or Stacke, 
operation. The modified mastoid operation. Abscess of the 
neck from middle-ear and mastoid suppuration. 



CONTEXTS. XI 

CHAPTER XVI. 

PAGE 

Diseases of the Internal Ear 183 

Hyperaemia and anaemia of the labyrinth. Inflammation of the 
labyrinth. Panotitis. Haemorrhage into the labyrinth. Meni- 
ere's disease. Leucocythaemie deafness. Syphilis of the laby- 
rinth. Diseases of the auditory nerve. Neuroses of the per- 
ceptive apparatus. Hyperaudition. Hyperesthesia. Paracusis. 
Paracusis Willisii. Subjective sounds, or tinnitus aurium. 
Nervous tinnitus. Spasmodic noises. Paresis and paralysis of 
the auditory nerve. Cerebral causes of deafness. Xew growths 
of the internal ear. 

CHAPTER XVII. 

Diseases of the Internal Ear, Concluded 191 

Injuries of the labyrinth. Deaf-mutism. Education of the deaf. 
Hearing-instruments. 



PAET II. 

DISEASES OF THE XOSE. 

CHAPTER XVIII. 
Examination and Instruments 205 

Examination of patients. Instruments. Atomizers. Vaporizers. 
Sprays. Inhalents. Inhalers. 

CHAPTER XIX. 

Diseases of the X'asal Cavities 219 

Acute rhinitis, or eoryza. Influenza. Simple chronic rhinitis. 
Chronic nasal catarrh. 

CHAPTER XX. 

Diseases of the Nasal Cavities. Continued 229 

Hay fever. The neurotic theory. Uric acid as a cause of hay 
fever. Predisposing and aggravating causes. 

CHAPTER XXI. 

Diseases of the Nasal Cavities, Continued 244 

Hay fever, continued. Symptomatology. Diagnosis. Prognosis. 
Abortive treatment. Local self-treatment. Preventive treat- 
ment. Hygienic measures. Symposium of medical opinions. 

CHAPTER XXII. 

Diseases of the Nasal Cavities. Continued 255 

Hypertrophic rhinitis. Electric-cautery apparatus. Surgical dv- 
namomotors. Operations for hypertrophies. Atrophic rhinitis, 
or dry catarrh. Ozena. 



Xll CONTENTS. 

CHAPTER XXIII. 

PAGE 

Diseases of the Nasal Cavities, Continued 272 

Epistaxis, or nose-bleeding. Mucous polypi. Fibrous polypi. Cys- 
tic polypi. Papillomata. Erectile tumors. Chondromata. Osteo- 
mata. Exostoses. Rhinoliths. Sarcomata. Carcinomata. 

CHAPTER XXIV. 

Diseases of the Nasal Cavities, Concluded 280 

Tuberculosis of the nose. Syphilis of the nose. Lupus of the nose. 
Glanders. Furunculosis. Anosmia. Parosmia. Deformities and 
diseases of the nasal septum. Blood-tumors of the nasal septum. 
Abscess of the septum. Perforation of the septum. Fractures 
of the nose. Congenital deformities of the nose. Foreign bodies 
in the nose. Animate objects in the nose. 

CHAPTER XXV. 

Diseases of the Accessory Cavities of the Nose 297 

Inflammation of the antrum of Highmore, or maxillary sinus. 
Ethmoid diseases. Sphenoid diseases. Diseases of the frontal 
sinuses. 

CHAPTER XXVI. 

Related Diseases of the Eye and Nose 307 

Diseases of the eye caused by nasal affections. Ocular reflexes 
from nasal diseases. Nasal diseases due to ocular anomalies. 

CHAPTER NXVII. 

Diseases of the Naso-pharyngeal Cavity 317 

Naso-pharyngeal catarrh. Atrophic catarrh of the naso-pharynx. 
Fibrous 'polypi of the naso-pharynx. Fibromucous polypi of the 
naso-pharynx. Malignant tumors. Adenoid vegetations in the 
vault of the pharynx. 



PAET III. 
DISEASES OF THE PHARYNX. 

CHAPTER XXVIII. 

Diseases of the Pharynx 335 

Acute pharyngitis, or simple sore throat. Simple chronic pharyn- 
gitis. Acute rheumatic pharyngitis. Chronic rheumatic sore 
throat. 

CHAPTER XXIX. 

Diseases of the Pharynx, Continued 347 

Sore throat of measles, scarlet fever, and small-pox. Follicular 
pharyngitis. Membranous sore throat, non-diphtheric. 



CONTENTS. Xlll 

CHAPTER XXX. 

PAGE 

Diseases of the Pharynx, Continued 355 

Diphtheria. Pathology. Etiology. Symptomatology. Diagnosis. 
Prognosis. 

CHAPTER XXXI. 
Diseases of the Pharynx, Continued 365 

Diphtheria, continued. Treatment. Examination of diphtheric 
patients. Isolation. Local and constitutional treatment. 

CHAPTER XXXII. 

Diseases of the Pharynx, Continued 375 

Diphtheria, continued. Serum-therapy, or the antitoxin treatment 
of diphtheria. The production and action of antitoxin. The 
time and methods for using antitoxin. The dosage. The results 
of blood-serum therapy. Symposium of opinions and experiences, 
both for and against antitoxin treatment. 

CHAPTER XXXIII. 

Diseases of the Pharynx, Continued 399 

Tonsillitis. Phlegmonous tonsillitis. Hypertrophy of the tonsils. 
Tonsillotomy. Instruments and methods of operating. Haemor- 
rhage following removal of the tonsils. 

CHAPTER XXXIV. 

Diseases of the Pharynx, Continued 414 

Mycosis, or parasitic disease of the pharynx. Concretions in the 
tonsil. Non-malignant tumors of the pharynx. Adhesions of 
the soft palate to the pharyngeal walls. Uvulitis. Bifid and 
double uvulas. Tuberculosis of the pharynx. Syphilis of the 
pharynx. Cancer of the pharynx. 

CHAPTER XXXV. 

Diseases of the Pharynx, Concluded 433 

Retropharyngeal abscess. Xeuroses of the pharynx. Xeuroses of 
sensation. Hyperesthesia. Anaesthesia. Paresthesia. Neu- 
ralgia. Neuroses of motion. Spasms of the pharynx. Globus 
hystericus. Pharyngeal chorea. Paralysis of the pharynx. 
Burns and scalds of the pharynx. Foreign bodies in the pharynx. 



PAET IV. 

DISEASES OF THE LARYNX. 

CHAPTER XXXYI. 

Diseases of the Larynx 443 

Indirect laryngoscopy. Instruments. Apparatus. Difficulties of 
laryngoscopy. Direct laryngoscopy, or autoscopy. 



XIV CONTEXTS. 

CHAPTER XXXVII. 

PAGE 

Diseases of the Larynx, Continued 452 

Acute laryngitis. 

CHAPTER XXXVIII. 

Diseases of the Larynx, Continued 159 

Croup. Comparison of true croup with laryngeal diphtheria. 

CHAPTER XXXIX. 
Diseases of the Larynx, Continued 464 

Intubation of the larynx. Instruments, method, and results. Care 
and feeding of patients. Tracheotomy. 

CHAPTER XL. 

Diseases of the Larynx. Continued 474 

Chronic laryngitis. Atrophic laryngitis. Suppurative laryngitis. 
Abscess of the larynx. Trachoma of the vocal cords. (Edema 
of the larynx. 

CHAPTER XLI. 

Diseases of the Larynx. Continued 486 

Xeuroses. Spasmodic croup. Anomalies of sensation. Nervous 
aphonia. Reflex affections of the voice. Paralyses. 

CHAPTER XLII. 

Diseases of the Larynx, Continued 494 

Tuberculosis of the larynx. Syphilis of the larynx. 

CHAPTER XLIII. 

Diseases of the Larynx, Concluded 502 

Tumors. Innocent tumors. Papillomata. Fibromata. Pachyder- 
mia laryngis. Miscellaneous growths. Malignant tumors. Car- 
cinomata. Sarcomata. Foreign bodies in the larynx. 

CHAPTER XLIV. 

Life-insurance Affected by Diseases of the Ear. Nose, and 

Throat -515 

APPEXDIX. 
Remedies -5-1 

Case-record Book 529 

Index 541 



LIST OF ILLUSTRATIONS. 



FIG. p AGE 

1. Arrangement of instruments and apparatus ! . . . . 13 

2. Pynchon's cabinet for instruments, etc 14 

3. The author's light-condenser 15 

4. Spring-band mirror-holder 16 

5. The author's adjustable bracket 17 

0. Toynbee's ear-specula 18 

7. Gruber's ear-specula 18 

8. The author's massage otoscope 18 

9. The author's cotton-carrier 19 

10. Normal drum-head of right ear 20 

11. Normal drum-head of left ear 20 

12. Outer surface of the left tympanic membrane of an adult. . 21 

13. The author's automatic tuning-fork 23 

14. Hartmann's tuning-forks 24 

15. Galton's whistle 26 

16. Politzer's acoumeter 27 

17. The author's original compressed-air meter 30 

18. Davidson cut-off 31 

19. Dilators and combined air-reservoir and hand-pump 36 

20. Compound hydraulic pump beneath the water-basin 38 

21. Single-acting hydraulic pump 39 

22. Eotary air-pump 40 

23. Air-meter of improved pattern . 41 

24. Politzer's air-bag 42 

25. Buttle's inflator 42 

26. The author's improved inflator 43 

27. Eustachian catheter 43 

28. Vertical section of the naso-pharynx with the catheter introduced 

into the Eustachian tube 44 

29. Fixation of the catheter with the left hand 45 

30. Toynbee's auscultation-tube 45 

31. Gangrene of the ear; mastoid operation 49 

32. Hypertrophied auricle 53 

33. Alpha syringe 58 

34. Author's small powder-blower for the ear 60 

35. Ear-forceps 65 

36. Rupture of the anterior-inferior segment of the drum-head caused by 

a box on the ear 67 

37. Section through the tympanic membrane, malleus, and upper and 

outer tympanic wall of a decalcified preparation 6S 

38. Eustachian tube and tympanic cavity 70 

39. Eadiate vascular injection of the drum-head 74 

40. Eadiate vascular appearance in acute inflammation of the middle ear. 7-i 

41. Convexity of the drum-head due to pressure from within 78 

42. Xipple-shaped bulging of the posterior portion of the drum-head, on 

the summit of which is the perforation 81 

43. Fluid effusion in the tympanic cavity, marked by a bright line 83 

44. Circumscribed bulging of the drum-head, due to pressure of fluid in 

the middle ear S3 

45. Great concavity of the drum-head and foreshortening of the hammer- 

handle 84 

(XT) 



XVI LIST OF ILLUSTRATIONS. 



FIG. PAGE 

46. Semilunar chalky deposit in front of the handle of the mallet 91 

47. Niche of the fenestra ovalis, with the crura of the stapes, in the nor- 

mal ear of an adult 91 

48. Marked retraction of the drum-head 96 

49. Circumscribed depressions in the anterior-inferior quadrant of the left 

drum-head 96 

50. Circumscribed adhesion of the membrana tympani to the promontory 

underneath the handle of the mallet 97 

51. Lucse's pressure-probe 99 

52. The author's ossicle-vibrator 104 

53. Section of the posterior fold of the membrana tympani 105 

54. Internal surface of the left membrana tympani 106 

55. Triangular resection, of the drum-head 107 

56. Middle-ear instruments and handle Ill 

57. The author's ossicle-hook Ill 

58. Politzer's pincette 112 

59. Vertical section of the external meatus, membrana tympani, and tym- 

panic cavity 113 

60. Extensive destruction of the drum-head 116 

61. Pear-shaped perforation of the drum-head 117 

62. Perforation of the posterior half of the right drum-head 117 

63. Destruction of the inferior half of the membrana tympani laying bare 

the promontory and niche of the round window 118 

64. Large perforation of the right drum-head 118 

65. Destruction of inferior half of the drum-head. Globular granulations 

on the inner wall of the middle ear 120 

66. Slender middle-ear probe 120 

67. The author's large powder-blower for use with a hand-bulb or com- 

pressed air 122 

68. The author's ear-aspirator 125 

69. Politzer's polypus-forceps 128 

70. The author's middle-ear case 128 

71. The author's caustic applicator on flexible shank 129 

72. Vertical section of middle ear; drum-head in contact with the inner 

wall 130 

73. Band-like cords between the lower end of the hammer-handle and the 

stapedo-incudal articulation 131 

74. Central perforation of the drum-head and calcareous deposits 131 

75. Facial paresis. Appearance the same as in permanent facial paralysis. 

The patient is photographed while laughing. 134 

76. Same as Fig. 75, three months after Stacke operation and treatment 

with electricity 135 

77. The author's ear-electrodes, attached to a head-band 137 

78. Sequestra of dead bone, and the ossicles. Actual size _ 139 

79. Post-mortem section of the temporal bone, showing a perforation of 

the lateral (sigmoid) sinus 14° 

80. The author's middle-ear curette 141 

81. Horizontal section of the ear 141 

82. Interior of base of skull 150 

The author's ice-bag : 15? 

T>,,^1,'^ -.-.t^ o + ^iz-1 Vt-ii-Fq lOO 



83. 

84. Buck's mastoid knife. 

The Nevius electric head-lamp 15 ° 



80. _ 

86. A strong scalpel j^i 

87. The author's mastoid chisel. Actual width J5< 

88. The author's long mastoid gouges. Actual width 15/ 

89. Lead-filled mallet 15 ^ 

90. The author's set of curettes |5b 

91. The author's mastoid guide j^j 

92. Mathieu's tongue-holding forceps loJ 



LIST OF ILLUSTRATIONS. XY11 



FIG. PAGE 

93. The author's periosteum elevator 159 

94. The author's self-retaining retractors 160 

95. A mastoid operation . , 163 

96. Operating-room and accessories 164 

97. Horizontal section through right temporal bone, cut two millimetres 

above the centre of the external canal 165 

98. Side-view of a skull, showing opening in mastoid process for 

Schwartze operation 166 

99. Schwartze operation 167 

100. Opening of the antrum 168 

101. Horizontal section through right temporal bone, showing distance 

between lateral sinus and external canal 169 

102. Horizontal section through right temporal bone, cut near centre of 

external meatus, showing how close the lateral sinus may come 

to the external canal in some cases 169 

103. Perpendicular section through the right temporal bone 170 

104. Adhesive-plaster dressing for mastoid wound 171 

105. Line of incision healed two months after Schwartze operation 171 

106. The Stacke operation completed 172 

107. Side of skull, showing Stacke operation 173 

108. Vertical section through the ear 174 

109. Section of the temporal bone. Actual size Facing 174 

110. Section of the temporal bone. Natural size Facing 174 

111. Horizontal section of temporal bone, cut near floor of external 

meatus 175 

112. Six weeks after Stacke operation 176 

113. Appearance two weeks after the modified operation. Healed five 

weeks after the operation 177 

114. Post-mortem section of mastoid process 178 

115. Appearance three weeks after a modified Stacke and an operation for 

a neck-abscess 179 

116. Abscess of the mastoid process extending over ten weeks, resulting 

in an enormous abscess of the neck, reaching nearly to the 

thoracic cavity 180 

117. The same as Fig. 116, showing the outline of the swelling 181 

118. The conical conversation-tube 199 

119. The London horn 199 

120. Electric illuminator, as used in posterior rhinoscopy 205 

121. Xasal speculum of correct pattern, and the proper way to handle it. . 206 

122. Bosworth's tongue-depressor 207 

123. Throat-mirrors 207 

124. White's palate-retractor 208 

125. Hard-rubber palate-elevator 208 

126. The posterior rhinoscopic image 209 

127. The Davidson spray-producers 210 

128. The De Vilbiss atomizer 210 

129. The lavolin atomizer 211 

130. Truax, Greene & Company's atomizer 211 

131. Andrews's combined atomizer and vaporizer 212 

132. The Universal vaporizer 213 

133. The Globe nebulizer 214 

134 to 139. Methods of receiving sprays and inhalents 214 

140. Hot-water inhaler 217 

141. The author's camphor-menthol inhaler 217 

142. The author's soft-rubber nasal bougie 228 

143. Xasal synechia 255 

144. Posterior view of osseous bridge shown in Fig. 143 256 

145. Transverse vertical section through the vault of the pharynx and 

Eustachian tube 256 



XV111 LIST OF ILLUSTRATIONS. 



FIG. PAGE 

146. Transverse vertical section through the posterior nares 257 

147. Transverse vertical section through the orbits, nasal fossae, and 

maxillary antra 258 

148. Transverse vertical section through the nasal fossse 258 

149. The Wabash cautery battery, with electrodes, lamp, and handles. . . 260 

150. The American storage battery. 261 

151. Electric current-transformer and dynamomotor 262 

152. Alternating electric current transformer for cautery purposes 263 

153. Cautery-knife 264 

154. Mcintosh electrocautery handle, with snare and windlass 264 

155. Hobby's steel snare 267 

156. The author's septum-knife 268 

157. The author's nasal saws 268 

158. Bellocq's cannula introduced. 273 

159. Curette-forceps 275 

160. Very strong cutting forceps 275 

161. Casselberry's saw-tooth scissors 276 

162. Destruction of the hard palate, the soft palate remaining unharmed. . 278 

163. Destruction of the bones forming and supporting the bridge of the 

nose 281 

164. Partial destruction of the bones of the nose, resulting in two per- 

forations 282 

165. The author's nasal supporter 283 

166. Moderate deflection of the septum nasi . 288 

167. Deflection of septum nasi sufficient to cause stenosis of the left naris. 288 

168. Deflection of septum nasi toward the right side, at nearly a right 

angle 289 

169. Deflection of septum nasi toward the left side with apparent, but 

not real, adhesion to the left inferior turbinated body 289 

170. Perpendicular portion of the ethmoid bone, consisting of two plates; 

the inferior turbinated bone of the left side is plainly visible . . . 290 

171. Transverse vertical section through the nasal fossse , 290 

172. Transverse vertical section through the nasal cavities 291 

173. Hartmann's forceps * • • ■ ■ 295 

174. Transverse vertical section through the nasal fossae and maxillary 

antra 297 

175. Transverse vertical section of the nasal fossae 298 

176. Transverse vertical section through the maxillary antra 299 

177. Transverse vertical section through the maxillary antra 300 

178. Cannula and trochar 300 

179. Longitudinal vertical section (actual size) through the nasal and ac- 

cessory cavities 30l 

180. Longitudinal vertical section (natural size) through the nasal and 

accessory cavities 304 

181. Dissection showing nasal duct and its relations 308 

182. Ducts connecting the nose with the accessory sinuses and the eye. . . 309 

183. Lacrymal knife 316 

184. Contracted upper jaw; narrow roof of mouth with very high arch, 

encroaching upon the nasal fossae 324 

185. A mouth-breather • 325 

186. Denhart's mouth-gag 3 -' 

187. Position of child for adenoid operation or intubation; mouth-gag 

introduced 3-o 

188. Gottstein's ring-curette 6 '- } 

189. Diphtheria bacilli 3ob 



190. Diphtheria bacilli. 

191. Streptococcus pyogenes 



35 

358 



192. The author's tonsillotome, with excised tonsil 408 

193. Adhesion of soft palate to the posterior Avail of the pharynx 41/ 



LIST OF ILLUSTRATIONS. XIX 



FIG. PAGE 

194. Bifid uvula in a man sixty years old 418 

195. Complete double uvula in a boy of fourteen years 419 

196. Large perforation of the velum palati 425 

197. Destruction of the velum palati 426 

198. Small powder-blower with long tube 429 

199. Mackenzie's lateral throat-forceps 439 

200. De Vilbiss illuminator 444 

201. Position for autoscopy 448 

202. Tongue-depressor for pharyngoscopy and direct laryngo-tracheoscopy. 448 

203. Tangential plane * * 449 

204. Standard spatulas 450 

205. Types of instruments for autoscopie operations 451 

206. O'Dwyer's intubation-tubes 464 

207. Scale * 464 

208. O'Dwyer's introducer, with tube attached 465 

209. O'Dwyer's extractor 465 

210. Eoswell Park's aluminium tracheal tube 470 

211. Hard-rubber tracheal tube 471 

212. Trachea dilator 472 

213. Laryngeal cotton-forceps 479 

214. Tobold's set of six forceps, knives, etc 506 

215. Mackenzie's antero-posterior laryngeal forceps 507 



PART I. 



Diseases of the Ear. 



(i) 



CHAPTEE I. 

A GENERAL CONSIDERATION OF DISEASES OF THE EAR, NOSE, 
AND THROAT BASED ON A STUDY OF TWENTY-ONE THOUSAND 

CASES. 

The following statistical tables represent the records of 21,000 
cases treated during seventeen years at one of the author's clinics in 
Chicago. The first table formed a part of a report made by the author 
to the Ninth International Medical Congress in 1887; the second 
was compiled for me by my assistant, Charles L. Enslee. A relatively 
small number of unselected cases have been added from the records 
of my private practice to supply the place of those whose records were 
incomplete. The first classification was instituted for the purpose of 
establishing a basis of calculation of the influence, if any, exerted by 
occupation, age, or sex in the causation of ear diseases. The con- 
dition of each patient at the time he first presented himself at the 
clinic is given in order to determine the relative frequency of the 
different diseases. 

As is common in charity hospitals, a considerable number of 
those who applied for treatment belonged to that class of laboring- 
people who have no definite trade or fixed occupation. In order to 
facilitate investigation and simplify the tables as far as possible, all 
those occupations that were closely related to each other in nature 
and effects were grouped under one heading. For example, under 
the classification of clerks were embraced salesmen, book-keepers, 
office employees, etc.; with teamsters were grouped car-drivers, ped- 
dlers, etc.; cooks and bakers were classed together; brass-molders, 
iron-molders, etc., were classified with iron-workers; plumbers, gas- 
and steam- fitters appear together; such closely-allied occupations as 
stone-cutters, stone-masons, brick-layers, and plasterers, in which the 
influences and exposures are very similar, are grouped together under 
the head of day-laborers, — a term borrowed from the laborers them- 
selves. 

(3) 



4 CLASSIFICATION OF PATIENTS AND DISEASES. 

The abbreviations employed are: 

W. No., for whole number. 

Ac, for acute inflammation of the middle ear. 

Ac. S., for acute suppurative inflammation of the middle ear. 

C. N., for chronic non-suppurative inflammation of the middle ear. 

C. S., for chronic suppurative inflammation of the middle ear. 
Ext., for diseases of the external ear. 

Int., for diseases of the internal ear. 

D. M., for deaf-mutes. 
F. B., for foreign body. 

In. C, for inspissated cerumen. 
Fur., for furuncle. 

Ac. S. N. for acute suppurative inflammation of one middle ear with 
chronic non-suppurative inflammation of the other. 
Au. P., for aural polypus. 
M. D., for mastoid disease. 
N. Ph., for naso-pharyngeal catarrh. 
Ad., for adenoid growths in the vault of the pharynx. 
Hy. T.j for hypertrophied tonsils. 



Occupation. 



Miners . 

Firemen . . ... 

Coopers 

Butchers 

Packing-house laborers 
Engineers . ... 

Cigar-makers .... 

Plumbers 

Boiler-makers .... 
Tinners . 

Shoe-makers . . . 
Bakers ..... 
Printers . . 
Tailors .... 

Blacksmiths . ... 

Painters 

Sailors ... 

Railroad-laborers . . . 

Farmers 

Carpenters 

Iron-workers .... 

Teamsters 

Factory-hands .... 

Clerks 

Day -laborers 



Total 



1 

£ 


< 


10 




10 




10 


1 


11 


1 


12 


1 


13 




15 


2 


16 


2 


19 




20 


1 


22 




22 


1 


30 




31 




38 


1 


47 


3 


47 


1 


58 


2 


74 




80 


3 


84 


4 


85 


12 


108 


6 


232 


17 


496 


27 


1590 


85 



1 
1 

3 
4 

2 

2 

2 

2 

2 

1 

2 

5 

1 

4 

4 

11 

13 

19 

26 



109 



9 

5 

6 

8 

10 

6 

7 

10 

9 

14 

14 

10 

18 

26 

26 

28 

35 

55 

57 

54 

33 

59 

117 

300 



922 



4 

1 

1 

3 

2 

2 

3 

1 

3 

5 

1 

4 

12 

8 

3 

10 

9 

12 

18 

8 

11 

23 

19 

39 

77 



279 



10 
6 

9 
36 



171 



24 



CLASSIFICATION OF PATIENTS AND DISEASES. 



Summary. 
















1 


6 
< 


X 

< 


"J 


6 


+3 


. 


ft 


Adult males without occupation . . 

Female adults 

Boys, 6 to 15 years 

Girls, 6 to 15 years 

Boys under 6 years 

Girls under 6 years 


810 
1662 
557 
562 
243 
276 
1590 


43 
75 
35 
32 
11 
11 
85 


31 

63 
28 
22 
21 
26 
109 


485 
1070 

230 

225 
41 
45 

922 


197 
317 
205 
232 
125 
139 
279 


46 
106 
34 
35 
26 
38 
171 


7 
27 
19 
11 
8 
9 
24 


1 
4 
6 
5 
11 
8 


With occupations 




Total 


5700 


292 


300 


3018 


1494 


456 


105 


35 


Percentage of W. Xo 




5.1 


5.3 


53. 


26. 


8. 


2. 


0.6 



The combined tables show that, of the 21,000 cases, there are 
11,167 patients with occupations, classified under 28 headings. Of 
this number, 3813 had ont-door and 7354 in-door work. In the 
first table a larger proportion would undoubtedly have appeared as 
belonging to in-door occupations had as much care been exercised in 
eliciting the exact nature of the vocations of so-called day-laborers 
as was used during the time covered by the second table. About 34 
per cent, are out-door and 66 per cent, in-door occupations, or about 
twice as many in-door occupations as out-door. 

The largest number of any one class were in-door workers, — 
3014 domestic servants. Xext in order were about half that number 
of the out-door class, or 1493 day-laborers. Then follow groups of 
the next highest numbers: 858 clerks, 460 iron-workers, 452 car- 
penters, 420 factory-workers of all kinds, and 400 sewing-women, — 
all in-door occupations, until we reach the out-door class again in 
going down the list. 

While the great stores and factories furnish a large number of 
patients, the homes contribute 5615 females, including the servants, 
seamstresses, and women without occupation, or more than one- 
fourth the whole number of the combined tables. These facts are 
significant when we take into account the slight difference between 
the number of males and females affected under the age of 15 years. 
Out of 6154 children under 15 years there were 1484 boys and 1582 
girls between the ages of 6 and 15 years, and 1641 boys and 1447 
girls under 6 years. Of all these children 3029 were girls and 3125 
boys, leaving a difference of only 96 more males than females under 



CLASSIFICATION OF PATIENTS AND DISEASES. 



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Miners . . . 
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Professions . . , ,. 
Railroad-laborers . . 
Sailors . . . 
Sewing-women . . . 
Shoe-makers . . 
Tailors . . . . 
Teachers . 

Teamsters .... 
Tinners . . 
No occupation, males 
No occupation, females 
Boys, 6 to 15 years 
Girls, 6 to 15 years 
Boys under 6 years 
Girls under 6 years 




Bakers ... 

Blacksmiths 

Butchers . . . 

Carpenters . . 

Cigar-makers . . 

Clerks . . 

Coopers . . 

Day-laborers 

Domestics 

Engineers 

Factory-workers 

Farmers 

Iron-workers 

Janitors 


lis 
o 
H 



CLASSIFICATION OF PATIENTS AND DISEASES. 7 

15 years. Between the ages of 6 and 15 years there were 95 more 
girls than boys. Under 6 years there were 194 more males than 
females. 

Sex seems to have no influence in the production or prevention 
of diseases of the ear, nose, and throat. It appears that up to the 
age of 15 years both sexes suffer nearly equally. Possibly a reason 
for this may be found in the similarity of the lives and habits of the 
sexes during this early period. But the classes of society that afford 
clinical material at the medical charity institutions are such that 
necessity requires them to abandon the pursuit of an education at 
about the fifteenth year, and to enter upon bread-earning vocations. 
Thenceforth the divergence in habits and environments increases. 
The males are either out-of-doors more than ever or confined chiefly 
to mercantile houses and factories. The females become domestics, 
clerks, shop-girls, and seamstresses. 

An interesting question pertains to the relative frequency of 
diseases of the right and of the left ear, and of diseases of one ear 
as compared with diseases existing coincidently in both ears. The 
second table shows that in acute inflammation of the middle ear 
there is but a very slight difference in the frequency of involvement 
between the two ears, not referring to the question of sex, and both 
ears were affected in 43 per cent, of all the cases. In acute sup- 
puration of the middle ear, again, there is too little difference between 
the two ears to take into account. In 15 per cent, of all these cases 
both ears were involved. 

In 2790 cases of unilateral ear diseases which the author has 
investigated to determine which ear was the more frequently affected, 
especially with reference to the question of sex and its influence, 
first in children under 15 years of age, and, second, in adults, the 
results are as follow: There were 456 boys with affections of one ear 
only, of whom 245 had diseases of the right ear, and 211 diseases of 
the left ear, an excess of about 7.6 per cent, of right ear affections. 
Of 569 girls, 334 had diseases of the right and 235 diseases of the 
left ear, or an excess of 17.4 per cent, of affections of the right ear. 
This shows that out of the total number of 1025 children under 15 
years there was an excess of 25 per cent, of diseases of the right ear. 

Of 1046 men, 472 had diseases of the right ear, and 574 of the 
left, or an excess of about 10 per cent, of affections of the left ear. 
There were 719 women, of whom 363 presented troubles of the right 
ear, and 356 of the left, or an excess of diseases of the right ear 
amounting to a trifle less than 1 per cent. 



8 CLASSIFICATION OF PATIENTS AND DISEASES. 

In the 5809 cases of chronic non-suppurative inflammation of 
the middle ear the two sides were abont equally affected, but a great 
contrast is now offered in the relative frequency with which both ears 
are involved in the various middle-ear diseases, for in this instance 
nearly 82 per cent, of all the cases presented bilateral aural affection. 
Sufficient importance must be attached to these undeniable figures 
in formulating our prognosis when only one ear is already diseased, 
for it follows, almost as the night the day, that if one ear has become 
seriously affected, especially with the sclerotic form of dry catarrh, 
the other falls under the same destructive process. 

In chronic suppurative otitis media the two ears suffer nearly 
equally, and it appears that both ears are simultaneously affected in 
a little more than 60 per cent, of the cases. In 3185 instances of 
unilateral ear diseases there was an excess of only 23 cases of the 
right over the left ear. This fact is mentioned particularly because 
the opinion has often been expressed that one ear was much oftener 
affected than the other, some specialists believing that the right was 
by far the more frequently diseased. 

The tables show that about 13 per cent, were afflicted with naso- 
pharyngeal diseases, but the actual number would be far in excess 
of this figure. The institution being an eye and ear hospital strictly, 
not as great prominence has been given to the nose and throat affec- 
tions as would be desirable, this part of the diagnosis sometimes 
being entered on the patients' cards instead of upon the record-books. 

About 8 / 10 of 1 per cent, had diseases of the mastoid process, 
which was nearly twice as prevalent in males as in females. 

Deaf-mutes formed about 1 / 2 of 1 per cent, of the 21,000 cases. 
There were three times as many males as females. 

The largest number of any one class of diseases was 8827 with 
chronic non-suppurative inflammatory processes of the middle ear, 
or 42 per cent, of the whole number. Next in numerical order come 
3664 cases of chronic suppurative inflammation, or 17 per cent.; and 
the next highest number 1009 cases of acute suppuration, or 5 per 
cent. 

American residences and business houses are heated in cold 
weather by dry, hot air and kept at a temperature of 70° F. or 
higher. The inmates are subjected to ihe action of this dry heat, 
often laden with dust and noxious gases, the greater part of every 
day. The skin, consequently, is very active in its functions, and 
kept moist by free perspiration. But, though constant exposure 



ETIOLOGY OF DISEASES OE THE EAR, NOSE, AND THROAT. 9 

renders the soldier, Spartan-like, indifferent to cold and storms, 
housing the body makes it tender, like the hot-house plant, and 
sensitive to sudden and extreme changes in the air. After working 
all a winter-day in a temperature of summer-heat, these people, with 
the powers of resistance reduced by fatigue and hunger, pass out 
immediately into a frigid atmosphere, with the temperature perhaps 
from 40° to 70° F. lower than that of the work-shop. The skin is 
chilled, the perspiration checked, and a determination of blood to 
some internal organ occurs. Naso-pharyngeal catarrh is probably 
the most frequent consequence. This result is aggravated by high 
winds and the inhalation of dust. In fact, a very large percentage of 
naso-pharyngeal catarrh is undoubtedly due to the irritating effects 
of dust, and this, operating in conjunction with cold, damp air, is 
largely responsible for the wide-spread existence of naso-pharyngeal 
catarrh among Americans. It is undoubtedly the most prevalent 
disease in the United States. The importance of this fact is obvious 
when we consider that so large a number of middle-ear affections 
originate in naso-pharyngeal inflammation which extends through 
the Eustachian tube to the tympanum. Critical examination of the 
nose demonstrates the existence of nasal trouble in a large proportion 
of these cases. Hence, whatever causes a catarrh of the nose and 
throat is interesting to the otologist as a proximate cause of ear 
disease. 

The exanthemata are frequent causes of ear diseases during 
childhood, but youth seems to predispose to coryza, which is often a 
forerunner of tubal and tympanic catarrh. Children under 15 years 
of age constitute about 29 per cent., or more than one-fourth of the 
whole number of cases. A'ery many of them dated back to attacks 
of scarlet fever, measles, and the earaches and "running-ears" of 
infancy; so that a much larger percentage than appears should prob- 
ably be credited to the period of childhood. Only a small proportion 
of children were brought for treatment during the acute stage of 
inflammation. Only about 10 per cent, were acute cases, leaving 90 
per cent., or nine times as many, who had not applied for treatment 
until the inflammation had reached a chronic stage. Indeed, only 13 
per cent, of the adults were seen in the acute stage. 

The tables show a large percentage of diseases of the external 
ear. Since impacted cerumen may be regarded as a symptom and 
a consequence of chronic non-suppurative inflammation of the middle 
ear, due consideration should be given this fact in estimating the 



10 ETIOLOGY OF DISEASES OF THE EAK, NOSE, AND THKOAT. 

relative frequency of affections of the middle, and of the external, 
ear as shown in the tables. 

It may be permissible to cite a few facts that do not appear in 
the statistics, but which, nevertheless, were impressed upon me by a 
personal study of this class of patients. Although the whole State 
of Illinois contributed largely to the number embraced by these 
statistics, a large majority were residents of Chicago, — a very cosmo- 
politan city. The foreign element predominates. The nationalities 
were not recorded except in resident infirmary cases, but the Irish 
constituted a very large and the French a very small percentage of 
our clinical material. The north of Europe furnishes a far greater 
percentage of our population than the southern portions. After con- 
sidering the nationalities it will not be surprising when it is stated 
that the blondes exceed the brunettes in number. 

Another matter of interest to the etiologist, and to the student of 
sociology as well, was the conspicuous absence of baldness among 
these people, for cold draughts of air on heads deprived of nature's 
covering are considered by some authors as being a prolific cause of 
catarrh. 

This brings us to a consideration of the last topic of this chapter, 
— climatic causes. In speaking of climatic conditions as standing in 
a causative relation to these diseases, it should be understood that 
reference is had to those atmospheric conditions that are character- 
istic of the vicinity of the Great Lakes and the Mississippi Valley, 
although they may not be peculiar to it. A sudden great fall of 
temperature, accompanied with increased humidity of the air, is 
usually followed by an increase in the number of new patients with 
acute diseases of the ear, and of chronic cases with acute symptoms. 
These effects of atmospheric variations occur with such uniformity 
that we may predict an increase or decrease in the number of acute 
diseases with a reasonable degree of accuracy by observing the meteor- 
ological variations. Our climate is rugged, but the people born and 
reared in it do not seem to partake of its robust character. The 
altitude is low in the Mississippi Valley and the thermometric 
changes are sudden and great, It is not unusual for the ther- 
mometer to fall 20° or 30° F. or more in a few hours. Indeed, cold 
waves sweep suddenly over the country in summer-time, cooling the 
heated atmosphere so quickly and so thoroughly that one must needs 
change from summer to winter clothing with haste or suffer from the 
chilling winds. Add to these causes of great circulatory disturbances 



COMPARISON OF STATISTICS. 



11 



the irritating effects of constantly-inhaled dust, which the ceaseless 
winds keep in never-ending motion, and the problem of the prev- 
alence of naso-pharyngeal, tubal, and tympanic catarrh in our climate 
is, in a great measure, solved. 

Loewenberg, of Paris, in the Deutsclien medicifiischen Wochen- 
schrift, arrives at the conclusion that ear diseases have a particular 
predilection for the left ear. He believes that if one ear only is 
diseased it is more frequently the left. If the affection attack both 
ears it generally begins in the left, and leads here often to a more 
profound malady and to a higher degree of deafness than with the 
right ear. In this respect the sexes differ, in that the predominant 
deafness of the left side is peculiar to the male, while the reverse is 
true of female patients. Loewenberg examined 3000 cases of im- 
paired hearing, excluding causes lying in the external ear. Of the 
whole number there were 1790 males and 1210 females. He found 
among those affected with one-sided deafness 478 men and 311 
women. Of these, the right ear alone was afflicted in 212 men and 
167 women, and the left ear alone in 266 men and 144 women. This 
leaves about 12 per cent, more men afflicted with deafness of the 
left than of the right side, and about 7 per cent, more females with 
right-sided than with left-sided deafness. 

Of those suffering from bilateral deafness 1074 men and 737 
women were found, the right ear being the worse in 427 men and 
in 340 women; the left having the hearing more impaired in 647 men 
and in 397 women. There were 238 men and 162 women who were 
afflicted with a high degree of deafness affecting both ears equally 

B. Alexander Eandall has reported 4785 patients with 5412 
diseases, tabulated as follows: — 







Men. 






Women. 




E. Ear 


L. Ear 


Both Ears 


R. Ear 


L. Ear 


Both Ears 


Middle-ear diseases .... 


289 


271 


598 


198 


181 


586 


External-ear diseases. . 


86 


96 


196 


57 


58 


120 


Internal -ear diseases... 


4 


3 


5 


3 


1 







379 


370 


799 


258 


240 


706 



12 COMPARISON OF STATISTICS. 

It will be readily seen that this table shows slight variations 
in the relative frequency of diseases of the right ear as compared 
with the left, in the sexes. Among both men and women diseases 
of the right side predominated in middle ear affections, of the left 
side in external ear diseases, and of the right side again in troubles 
of the internal ear. There is quite a wide difference between the 
conclusions arrived at from the Paris statistics and the deductions 
justified by the Philadelphia and Chicago tables aggregating 25,785 
patients. During the past twelve years the author has taken pains 
to inquire of patients not only concerning the common causes of 
their varying diseases of the two ears, but also as to which ear they 
were in the habit of lying on mostly, in order to ascertain if that 
question could have any bearing on the one-sided character of their 
diseases, or on the fact of one ear's being worse affected than the 
other in bilateral affections, but no satisfactory solution of this 
problem has yet been evolved. 



CHAPTEE II. 
EXAMINATION OF PATIENTS. 

The examination of patients should be conducted so system- 
atically that no discoverable pathological process can escape detection. 




Fig. 1. — Arrangement of instruments and apparatus. 

Beginning with the right ear, both ears, both nares, and the throat 
should be minutely inspected. Patients often direct the surgeon's 
attention to one ear and remark that there is no trouble with the 
other, when examination reveals that both are affected in different 

(13) 



14 



EXAMINATION OF PATIENTS. 



degrees. The examiner should not be misled, but should investigate 
for himself; otherwise he is not in a position to do credit to himself 
or his art or do justice to his patron. 

A very convenient arrangement of a treatment-room is illustrated 
in Fig. 1. It shows, in a compact space, an adjustable gas-lamp, fitted 




Fig. 2. — Pynchon's cabinet for instruments, etc. 



with a light-condenser, and electric forehead-lamp; a compressed-air 
reservoir and regulator, with two treatment-tubes and cut-offs 
attached; a dynamomotor for transforming the electric current for 
cautery purposes and for operating the dental engine with drills, etc. 
The relative positions of the illuminator and the chairs for the patient 



EXAMINATION OF PATIENTS. 



15 



and surgeon are correctly given. Fig. 2 shows Pynchon's cabinet for 
instruments, medicines, sprays, etc. 

The aurist should sit facing the right side of his patient to begin 
the examination, with the light immediately behind the patient's 
head and on a level with his ear if it is an adult. In the case of a 
child the light should be on a level with the physician's eye. 

Time will be economized and labor facilitated by the use of an 
armless revolving-chair (Fig. 2) for the patient. The seat should be 
easily raised and lowered by a supporting centre-screw, fitted with 
sufficient nicety to prevent a rocking motion. The back should be 
unyielding and only high enough to support the patient's back 
beneath his shoulders. After examining the right ear neither the 




Fig. 3. — The author's light-condenser. 



physician nor the patient need rise to bring the left ear into the 
field of vision, for the patient's chair is easily turned half-way around, 
and the positions are correct to proceed, the lamp then resting in 
front of the patient. 

The best illumination is had from an Argand gas-burner. It 
has not been possible to obtain an incandescent electric lamp that 
will afford such an evenly-diffused light as the gas gives, and the 
mantles of the incandescent gas-burners are too easily broken to 
permit of their being used on adjustable brackets. The flame should 
be inclosed in a light-condenser (Fig. 3), not only to increase the 
effectiveness of the illumination, but also to protect the operator's 
eyes. If. the light is allowed to shine in one's eyes it contracts the 



16 EXAMINATION OF PATIENTS. 

pupils, interferes with perfect vision, and eventually impairs the sight. 
The condenser is constructed with a reflector instead of a lens. For 
this reason it is not top-heavy and requires no spring to hold it in 
place. By a slight stroke of the finger-nail or a probe, its position 
can be instantly varied without burning the finger. It fits over the 
Argand gas-burner or the large railroad-burners on oil-lamps. A 
special large size is made to fit the incandescent gas-burner. 

The three-inch forehead-mirror is worn over the eye that is next 
to the light, and the aperture in the mirror should fall opposite the 
pupil of the eye engaged in inspecting the ear, so that both eyes are 




Fig. 4. — Spring-band mirror-holder. 

shielded from the direct rays of light. The light should be thrown 
in such a manner as to bring the auditory meatus within the focus of 
the reflected rays. Except at a distance of 14 inches or more, the 
drum-head is seen with one eye at a time; so that the other eye may 
be kept closed. The mirror is best held in position by a self-retaining 
holder, like the spring head-band shown in Fig. 4. This has the 
advantage of never deteriorating or becoming soiled, and, with prop- 
erly-adjusted spring, it does not occasion the wearer a headache. It 
leaves the hair unruffled and is in every way more satisfactory than 
the cloth or rubber bands. The forehead-plate is lined with soft 
rubber, which renders it agreeable to wear and easy to cleanse. 



EXAMINATION OF PATIENTS. 



17 



The light should be adjustable to the varying positions and 
heights of patients. To accomplish this the author devised the lamp- 
bracket illustrated in Fig. 5. The lamp is easily adjustable to any 
point lying within a perpendicular line two feet in length;, and it 
will swing through the arc of a circle having a radius of three feet. 
The light may be placed either within a few inches of the surface to 
which it is attached or at a distance of three feet from the wall. To 
raise or lower the light it is necessary only to press the brake toward 
the arm above it, set the lamp at any desired level, release the brake- 
handle, and it then sets automatically. The gas is carried to the 




Fig. 5. — The author's adjustable bracket. 



burner through a rubber tube, and where there is no gas an oil-lamp 
is substituted for the Argand burner. 

The metallic ear-specula are preferable to the hard rubber, but 
they should be warmed, especially in cold weather, before inserting. 
The small end of the funnel should be oval, to correspond with the 
contour of the meatus. Toynbee's set of three sizes of short length 
are satisfactory (Fig. 6). The flanged border should be milled. 
Gruber's (Fig. 7) are also excellent, but they should be milled like 
Toynbee's to render them less slippery. The auricle needs to be 
drawn upward, outward, and backward in most cases to straighten 



18 



EXAMINATION OF PATIENTS. 



the canal while the speculum is introduced, but in children it is 
sometimes necessary to draw the auricle downward and backward. 

A massage otoscope should be employed for diagnostic purposes 
as well as for treatment. In no other way can it be determined how 
much mobility of the ossicles has been lost, and how much is regained 




o o o 

Fig. 6. — Toynbee's ear-specula. 




Oo o 

Fig. 7.- — Gruber's ear-specula. 



as the result of treatment. In 1887 the author devised the instrument 
shown in Fig. 8. It consists of a pneumatic chamber, a concave 
perforated mirror, and a lens, contained in a cylinder to which is 
attached forty-six centimetres (eighteen inches) of soft-rubber tubing 
and a diminutive air-syringe. The apex of the funnel is covered with 




Fig. 8. — The author's massage otoscope. 



a section of soft-rubber tubing to allow of its being fitted hermet- 
ically into the external auditory canal without causing discomfort. 
The mirror focuses the light upon the drum-head, and the syringe 
alternately rarefies and condenses the column of air in the air- 
chamber and meatus. The lens in the eye-piece gives a clear view 



EXAMINATION OF PATIENTS. 19 

of the drum-head and mallet under brilliant illumination and passive 
motion. By holding the otoscope with the axis of its cylinder at a 
right angle to the source of light, the rays are projected upon the 
drum-head. The easiest method is with the operator standing in front 
and a little to one side of the patient, the otoscope in the left hand 
for the right ear, and the right hand with the pump on the top of 
the patient's head. The position is reversed for the left ear. As 
soon as the light is thrown through the funnel the otoscope must be 
held steadily in its relation to the lamp, and if the drum-head is not 
in the field of vision the hand upon the patient's head must tip or 
turn his head until the drum is brought into view. Now the sight 
is fixed upon the hammer, while the piston-rod is drawn outward 
sufficiently to produce an outward excursion of the drum-head. Then 
it is pushed inward to condense the rarefied air and move the mem- 
brane inward. While these movements are being effected it is ob- 
served whether the mallet moves with the drum-head or not, and, if 
it does, how much freedom of movement is present as compared with 



Fig. 9. — The author's cotton-carrier. 

the normal mobility. In some old cases of sclerosis the mallet 
remains entirely motionless, while the membrane about it vibrates. 
In the normal ear both move freely in response to every inward and 
outward motion of the air-piston. 

Xo more force should be applied than is necessary to obtain 
the natural excursions of the drum-head and mallet, and ordinarily 
no discomfort is caused unless the funnel is pressed very firmly 
against the canal-wall. If a deep blush overspread ShrapnelFs mem- 
brane and the mallet, the procedure should cease for the time, so as 
not to occasion too great hyperemia. The forehead-mirror is not used 
with this instrument, since it contains its own mirror. Care must be 
taken to not allow the fingers to shade the reflector. 

The cotton-carrier is best made of soft silver, with round, 
twisted handle and roughened tip to engage the cotton (Fig. 9). It 
should be very delicate, so as to consume as little space as possible in 
addition to the cotton twisted upon it. In many instances cerumen 
or discharges have to be removed before the drum-head can be in- 
spected. The cotton-carrier usually suffices, but the beginner must 



20 



EXAMINATION OF PATIENTS. 



be reminded that the drum is more superficial in infants than in 
adults, and in no case should the membrana tympani be bruised. 

The novice ought to accustom himself to the appearance of the 
normal drum by inspecting patients who have healthy ears. Students 
may profitably study each other. The healthy drum-head (Figs. 10 




Fig. 10. — Normal drum-head of right ear. (After Politzer.) 

and 11 and Plate I) has a pearly-blue tint, is translucent, lustrous, 
and always presents a triangular reflection of light, the apex of which 
is at the lower extremity of the mallet-handle. This luminous tri- 
angle extends downward and forward toward the periphery of the 
antero-inferior quadrant of the membrane. The long leg of the anvil 
can often be seen extending downward and backward to articulate 




Fig. 11. — Normal drum-head of left ear. (After Politzer.) 



with the stirrup, the posterior leg of which is sometimes visible 
running upward and backward, both together forming a V-shaped 
figure posterior to the upper portion of the hammer-handle. Ex- 
tending from the short process of the mallet, which is a yellow, 
dot-like projection of the upper end of the handle, are two nearly 



TESTS TOR HEARING. 



21 



horizontal folds stretching forward and backward to the peripheral 
attachment of the membrane and separating the tense lower section 
from the membrana flaccida, or Shrapnell's membrane, above (Fig. 
12 and Plate I). 

For convenience of description the drum-head is divided into 
four sections by a projection of the axis of the handle of the mallet 
to intersect the circumference of the membrane above and below and 
an horizontal line intersecting the drum-head at its centre. The 
four segments into which the drum-head is divided by these inter- 
secting lines are called the anterior-superior, anterior-inferior, pos- 



s ms s 




Fig. 12. — Outer surface of the left tympanic membrane of an adult, 
enlarged three and one-half times, v, segment of the tympanic membrane 
lying in front of the handle of the malleus; h, posterior segment of the 
tympanic membrane; s, s, Prussak's striae, passing from the short process 
of the malleus to the spina tymp. post, et minor; ms, membrana Shrap- 
nelli. (After Politzer.) 

terior-superior, and posterior-inferior quadrants, for convenience of 
description. 

Diseased appearances are described in their proper chapters. 



Tests for Hearing. 

It is difficult ordinarily to test the hearing of one ear in such 
a manner as to exclude entirely the perception of the test by the 
other, except in the employment of very delicate sounds, like the 
ticking of a watch. Even this ticking may be heard by the opposite 



22 TESTS FOR HEARING. 

ear when it is normal. The watch-sounds are the most constant in 
intensity, the most convenient at hand, and therefore the most uni- 
versally used. The same side of the same watch should always be 
employed, since the variations in pitch and volume are great in 
different watches, and there is sometimes considerable difference in 
the loudness of the sounds emitted from the opposite sides of the 
same watch. Many tests should be made with adult persons of 
normal hearing to fix the average hearing-distance for any test-watch. 
This distance usually varies from 30 to 60 inches (76 to 152 centi- 
metres), and determines the denominator of the fraction that ex- 
presses the hearing-power of any tested ear. The number of inches 
or centimetres at which the watch is heard gives the numerator. 
For example: A patient hears my 30-inch (76 centimetres) watch 
only 10 inches (25 centimetres) with his right ear and only 6 inches 
(15 centimetres) with his left. We record the watch-test as follows: 
H. D. E., 10 / 30 ( 25 / 76 ); H. D. L., 6 / 30 ( 15 / 76 ); which reads: Hearing- 
distance for right ear is 10 / 30 , or 1 / 3 of the normal; for the left ear, 
6 / 30 or 1 /- of the normal distance. 

During the test the patient must keep his eyes closed, to elimi- 
nate the element of imagination. The watch should always be brought 
slowly from a distance toward the ear until the patient indicates that 
he distinctly hears the sound. This process needs to be repeated 
several times until it is demonstrated beyond doubt that he perceives 
the sound at the same point repeatedly. 

If the watch is not heard by bone-conduction it is brought into 
contact with the auricle, and if heard there the hearing is expressed 
as follows: ~ (f6") ? mean i n g contact for the watch. If not heard 
until pressed against the mouth of the meatus, it is recorded thus: 
P.I. (-T-jr), — pressure for the watch. In case the watch cannot be heard 
at all it is written: °/ 30 (V-e)- ^ n y° im g persons it can be heard by 
bone-conduction in contact with the mastoid process, upper teeth, 
forehead, etc., but it is not likely to be perceived from these points of 
contact by persons over 40 years of age. Great patience is required 
in testing children's hearing, for they quickly answer in the affirma- 
tive whether they hear the test-sound or not, especially when they 
can see the source of sound. 

Tuning-forks are necessary in making a differential diagnosis 
between diseases of the transmitting and of the receiving apparatus, 
and in cases where the watch-sounds are not heard. If but one fork 
is used it is better to employ one of 512 vibrations per second, — the 



TESTS FOR HEARING. 23 

universal standard of pitch. This is C one octave above middle C of 
the piano. It gives off fewer overtones, or harmonics, if the ends are 
rounded than if square, and if the vibrations are caused by an auto- 
matic hammer attachment (Fig. 13), producing a moderate and un- 
varying blow. Some are made with sliding clamps to prevent over- 
tones and to raise and lower the pitch. 

The fork-test is made by air-conduction similarly to the watch- 
test. For bone-conduction it is placed with the end of the handle 
resting on the mastoid, vertex, upper teeth, or forehead, with the 
shaft at a right angle to the bone-surface. The distance is recorded 
in terms of inches or metres, and the duration of the perception of 
sound is taken in seconds. Knowing the average distance and dura- 
tion for a given fork, the amount of loss or gain in the hearing-power 
can be quite accurately recorded. Hartmanifs set of five forks (Fig. 
11) are tuned to 128, 256, 512, 1024, and 2048 vibrations per second. 




Fig. 13. — The author's automatic tuning-fork. 

They are the C's of four octaves upward, beginning at the C below 
middle C of the piano. In the fork-test especial care must be exer- 
cised to ascertain that the patient distinguishes between the musical 
note and the mere concussion or tactile perception of the unmusical 
vibrations. The latter can be perceived by the fingers as well as by 
the skull. The percussion-stroke must also be distinguished against. 

The fork must not be held with an edge of its branches opposite 
the meatus; and it should not be brought to the meatus from before 
backward or from above downward, otherwise the interference of 
sound-waves in those positions extinguishes the sound. 

In making a differential diagnosis between diseases of the con- 
ducting mechanism and affections of the perceptive apparatus, the 
labyrinth, or nervous centres, the following tests are employed: — 

Schwabach's Test. — The most important use to which the 
tuning-forks are put is in making a differential diagnosis between 



24 



TESTS FOE HEARING. 



diseases of the conducting, and of the perceptive, apparatus. In 
case there is an obstruction to the conduction of sound-vibrations 
through the external auditory canal, or through the middle ear, to 
the healthy internal ear, it was discovered by Schwabach that a fork 
vibrating in contact with the cranial bones was heard longer in the 
affected ear than in a normal ear. The opposite is true when the 




Fig. 14. — Hartmann's tuning-forks. 



auditory nerve is diseased; the fork then is heard longer by a normal 



ear. 



If the examiner have normal ears, he compares the patient's 
perception of sound with his own; or he may compare the percep- 
tions of the patient with the average tests of his standard fork as 
ascertained with normal ears. By this means the increased or di- 
minished length of time that the patient perceives the musical sounds 
can be accurately obtained and recorded. For example: The fork 



TESTS FOE HEARING. 25 

is struck and placed quickly upon the patient's mastoid process; the 
patient indicates the instant that he ceases to perceive the sound; 
immediately the examiner brings the fork in contact with his own 
mastoid and notes whether he hears the vibrations after the patient 
fails to hear them. If so, labyrinthal disease is indicated. If he does 
not, he sounds the fork again and places it upon his own mastoid 
process; the instant the examiner ceases to perceive the sound he 
places the fork in contact with the patient's mastoid. If the latter 
hears the fork then, after the examiner's normal ear ceases to hear 
it, an obstruction to the conduction of sound, but not a disease of 
the auditory nerve, is indicated. 

The examiner notes, also, the number of seconds the patient's 
joerception lasts. There are elements of uncertainty and error in 
this test, for in elderly persons bone-conduction is poor, and when 
one ear is normal, or when both are unequally affected, the better 
ear will perceive the sounds and cause confusion. 

Rhine's Test. — Air-conduction is superior to bone-conduction 
normally. The fork is heard before the meatus twice as long as on 
the mastoid. AVhen the vibrations cease to be heard on the bone, if 
the fork, yet vibrating, is brought to the mouth of the meatus, it 
will again be heard by the normal ear (positive Einne). If the fork 
is heard longer by bone-conduction (negative Einne), there is trouble 
in the canal or middle ear. If the hearing is impaired equally for 
air- and bone- conduction, there is labyrinthal trouble. Lesion of 
the transmitting apparatus is shown by (1) gradual loss of percep- 
tion of both lowest and highest notes; (2) by bone-conduction becom- 
ing relatively better than air-conduction. Labyrinthal disease is 
characterized by (1) no alteration in the relative acuteness of per- 
ception of sound by air and bone, both being diminished; (2) by 
deafness for some tones, generally the higher. 

Weber's Test. — In normal ears the fork is heard better when 
in contact with the skull if the auditory canals are closed. If one 
ear is closed by the finger the sound is intensified. This phenomenon 
is probably due to increased resonance of an inclosed space and ob- 
struction to the exit of sound-waves. This has been observed in 
adhesions, when the middle ear contained fluids, and when the drum- 
head was relaxed. 

Sing's Test. — After the sound of the tuning-fork vibrating on 
the median line of the vertex or forehead ceases to be heard, if the 
external canal is then closed by the finger the sound will be again 



26 TESTS FOR HEARING. 

perceived for a time by the normal ear. If this time is too brief, it 
indicates trouble in the transmitting apparatus. If this interval of 
secondary perception is normal, an existing ear disease must be 
referred to the labyrinth or nervous centres. 

Gelle's Test. — The mobility of the stirrup may be determined 
by condensing the air in the external meatus while the tuning-fork 
is vibrating on the head. If the stirrup is movable the sound of the 
fork is heard less distinctly or not at all during condensation, and 
dizziness or even vertigo may result. The condensation of the air 
may be produced by the pneumatic otoscope (Fig. 8) or by a rubber 
bag with an olive nozzle. 

Galton's Whistle. — This is useful in determining the loss of per- 
ception for the highest notes in cases of bilateral ear diseases. If 
one ear is affected but little or not at all, the whistle-sounds can 




Fig. 15. — Galton's whistle. 



scarcely be excluded from it. This instrument (Fig. 15) has a com- 
pass of about three of the highest octaves, and it is blown by means 
of a small rubber bulb. The tones can be varied by shortening or 
lengthening the cylinder by a screw mechanism. 

Politzer's Acoumeter. — This is an instrument of precision, which 
can be heard at a distance of forty-nine feet (fifteen metres) by the 
normal ear (Fig. 16). It is used very much like the watch directly 
opposite the opening of the canal, and the hearing-distances are re- 
corded similarly to those of the watch. It is held by the thumb and 
index finger resting in the semicircular plates, the thumb below, 
while the percussion-hammer is struck with the second finger. The 
cylinder which it strikes is tuned to C. To test bone-conduction 
the metal disc projecting from the perpendicular column is placed 
in contact with the mastoid process or the temple, while the meatuses 
are closed. I have observed that in sclerosis a patient may not be able 



TESTS FOE HEARING. 27 

to hear the acoumeter by air-conduction, although he may hear all of 
Hartmann's forks. 

Speech-test. — This would be the ideal test were it not that no 
two voices are of the same pitch, volume, and timbre or quality. 
Indeed, the same voice may vary greatly at different times, and even 
at the same examination. Yet an excellent idea of the amount of 
usefulness still retained by the organ of hearing can be demon- 
strated by the speech-test. It is customary to choose words varying 
greatly in the relative preponderance of vowel and consonant sounds, 
such as the names of different cities and states, and to request the 
patient to repeat these words after the examiner. In order to elim- 
inate the possibility of lip-reading the patient is required to keep his 
eyes closed during the examination. Since there is a tendency to use 
the same names repeatedly, in which case patients may introduce 




Fig. 16. — Politzer's acoumeter. 

the uncertain element of guessing, it is better to employ numerals. 
This gives a much wider range of sounds and lessens the chance of 
repeating the same sounds in the same order. Whispered speech is 
also used in addition to the low and loud tones. In advanced sclero- 
sis and labyrinthal affections whispered speech cannot be interpreted. 

Vowels are heard much farther than consonants, but both should 
be used in the examination. The test should be made with each ear 
separately while the opposite one is kept closed. In unilateral deaf- 
ness a test should be made with both ears sealed with the moist 
fingers: if then the sound is heard as well as before, it is demon- 
strated that the sound was perceived by the normal ear. 

Music is heard much better than speech. Many persons with 
greatly impaired hearing, unable to understand a lecture or sermon 
or the drama, can derive pleasure from an orchestra or opera. 



28 RECORDING CASES. 

A record of every case ought to be kept in a convenient book for 
that purpose. A very complete form, compiled by E. Pynchon, may 
be found at the end of this book. The following headings indicate 
the method pursued by the author,, the details being worked out as 
suggested by the characteristics of each case: — 






Date. 


Occupation. 


Particular Lesions. 


Name. 


Eesidence. 


Eesults of Tests. 


Age. 


History. 


Complete Diagnosis 


Sex. 


Duration. 
Cause. 


Treatment. 



CHAPTER III. 
COMPRESSED-AIR APPLIANCES AND THEIR USES. 

By a series of experiments with the compressed-air gauge the 
author has found that the maximum amount of pressure that can be 
obtained with a Politzer air-balloon of the capacity of eight fluid- 
ounces is 6 pounds; with the six-ounce bag the pressure may be 
made to reach 10 or 12 pounds. The difference in favor of the 
smaller bulb represents the greater advantage one has in grasping 
a small object. This amount was the maximum obtainable by an 
unusually strong hand, accustomed for years to compressing air-bags 
handled at the greatest advantage for leverage, — that is, with the 
larger end of the balloon between the thumb and strongest fingers* 
and the tapering end under the third and fourth, or weakest fingers. 
As the reverse method is practiced by many aurists, much less force 
than 6 and 10 pounds must result. 

Ten- and twelve- ounce bags are manipulated in Vienna by 
pressing them against the operator's side, but they are not much 
used in America. The Gruber balloons, with the opening or air-valve 
at the larger end, might possibly accumulate more force than we have 
mentioned, by repeatedly compressing them, but, on account of the 
valves being imperfect or soon becoming useless, we have discon- 
tinued their use. Professor Gruber himself prefers the bulb having 
a perforation in the end to be covered and compressed with the thumb. 
Experiments have not been made with this kind, for one could not 
be found. 

The rubber bulb usually supplied by the Davidson Company for 
hand-sprays and inflators can be made to exert 15 or even 18 pounds, 
but not by a single compression. However, it is not practicable to 
employ more than 15 pounds with the 3 / 16 -inch rubber tubing ordi- 
narily supplied with inflators. A higher pressure distends it, and 18 
pounds will rupture it with a loud report. The thick, firm, white 
tubes accompanying the De Vilbiss atomizers will stand more, for 

(29) 



30 



C03IPRESSED-AIB, APPLIANCES AND THEIR USES. 



I have tested them with 45 pounds' pressure without even distending 
them. 

The force necessary for spraying the nose and throat is not great. 
Eight pounds will project continuous sprays of watery solutions or 
lavolin with sufficient force from the Davidson atomizer. About 12 
pounds' pressure is needed to produce a continuous and copious 
lavolin-spray from the De Vilbiss atomizer, and it requires from 30 
to 40 pounds to throw a spray of unheated glycerole of tannin. 







Fig. 17. — The author's original compressed-air meter. 



In adapting the improved compressed-air apparatus to the treat- 
ment of the ear the author has endeavored to devise some means of 
determining and controlling the force and volume of air, or the 
dosage. As the illustration above (Fig. 17) will show, this has been 
accomplished by placing a pressure-gauge between two valves on the 
escape-tube of the air-receiver. This arrangement utilizes the gauge 
for registering not only the air-pressure in the reservoir, but also the 
force of the current of air while it is escaping at the cut-off of the 



COMPBESSED-AIE APPLIANCES AXD THEIB USES. 31 

treatment-tube. The cut-off that has proven most satisfactory is 
known as the Davidson (Fig. 18). 

The meter is used as follows: By opening the outer, right-hand 
valve marked 1, by turning the wheel to the left one-fourth of its 
circumference, pressing the thumb-valve of the cut-off, and opening- 
valve 2, gradually you may obtain any number of pounds' pressure 
desired at the cut-off, — from 1 up to the full amount of pressure in 
the reservoir. To use 10 pounds: with the cut-off and valve 1 open, 
turn the valve 2 until the index needle runs up to 10. As long as 
the cut-off remains open, the needle indicates 10 pounds. If you 
close the cut-off the needle rises to indicate the whole number of 
pounds in the reservoir. Xow. if you fit a spray-producer to the cut- 
off and open it, the first impulse of the column of air, which is small 
in volume, is expended in filling the atomizer and starting the spray. 
In using the nasal bulb of the inflator (Fig. 26) for treating the ear- 




Fig. IS. — Davidson cut-off. 

the first impulse is expended in tilling the nasal and superior pharyn- 
geal cavities in addition to inflating the middle ear. The volume of 
air is so small that the needle drops down to 10 at once and remains 
there as long as the cut-off is kept open. If no more than this amount 
is desired the cut-off should be opened before the current is turned 
on and valve Xo. 2 should be slowly opened until the needle indicates 
the number of pounds required. Xo greater pressure will then be 
exerted unless the cut-off valve is closed. 

"When it is desired to interrupt the air-current for the purpose 
of producing movements of the membrana tympani and ossicles, or 
to throw jets of volatilized medicine or sprays into the tympanic 
cavity, it is a simple matter to control the pressure in this way. Let 
us assume that we want to use. with the nasal-tipped inflator adapted 
to this purpose. 2 atmospheres, or about 30 pounds. Talve 1 bein°- 



32 COMPRESSED-AIR APPLIANCES AND THEIR USES. 

opened, apply the cut-off to the nasal bulb containing the medicine 
on sponges; open the cut-off; turn on 10 pounds with wheel 2 and 
then close the cut-off. The needle rises. Now, if the inflator is in- 
serted into the nostril with the patient's nose firmly closed and 
cheeks fully distended, the instant the cut-off is opened the needle 
runs down to 10. Close the cut-off and the needle mounts to 30 
pounds. Open the cut-off at that moment and the needle descends 
again to 10; close the cut-off and the needle rises; the instant it 
touches the 30 pounds' mark open the cut-off again and so on; re- 
peatedly opening and closing the cut-off will give repeated impulses 
at any given pressure below that in the reservoir. 

The resistance offered by the sponges is small, — less than one- 
third of an atmosphere. 

A little practice will enable any one to measure the doses skill- 
fully and to give effective treatments without fatigue. 

If very rapid interruptions are required, valve 2 should be opened 
more freely than in the example given. For 30 pounds' maximum 
pressure about 20 pounds should be allowed for the uninterrupted 
current. Experience with this method indicates that not more than 
60 interruptions per minute should be made in order to produce per- 
ceptible vibratory movements of the drum-head and ossicles. 

The dose of air for ear treatment varies greatly in different in- 
dividuals. While 15 pounds might endanger the continuity of an 
infant's drum-head or one greatly weakened by disease, or the thin 
cicatricial membranes closing old perforations, we have often applied 
60 or more pounds to old, thickened, and hardened drum-heads 
without rupturing them. 

It is evident that if it require 40 pounds in some cases to propel 
sprays into the middle ear, it follows that in such instances rubber 
air-bags are insufficient, for they do not average more than 6 to 15 
pounds. But with high pressure only a small volume' should be used. 
I would propose the following rule to keep the operator within the 
limits of safety: The higher the pressure, the lower the volume 
should be. If the density of the air is greater than one wishes to 
use, even with a minute volume, it is easy to avoid the high pressure 
when using the nasal-tipped inflator, by leaving the opposite nostril 
open during the first impulse, until the needle descends to the proper 
point. This allows the surplus air to escape by the opposite nostril. 
The same purpose is accomplished with the catheter by holding the 
catheter-tipped inflator (Fig. 17) a little withdrawn from the mouth 



COMPRESSED- AIB APPLIANCES AXD TIIEIE USES. 33 

of the catheter while the cut-off is first slowly opened. The surplus 
pressure then escapes at the junction of the inflator and catheter. 

The Yolurne should he proportioned to the density with care in 
cases of atrophied soft palate, so as not to strain the muscles of the 
throat by too powerful inflations, especially if they are subject to 
rheumatic sore throat. 

It serves a convenient purpose to instruct patients to raise one 
or both hands every time they feel one or both ears inflated. This 
obviates the necessity of frequently using the auscultating tube. 

The warnings against the danger of rupturing the membrana 
tympani by politzerization have been freely sounded. The author 
lias never ruptured a drum-head by compressed air, while he has 
seen a considerable number that were torn or perforated by blows 
on the ear. Even in men employed in caissons of tunnels, bridges, 
etc., where they are compelled to work in an atmosphere condensed 
under a pressure of 40 to 60 pounds, it is rare to find a ruptured 
drum-head. This may be owed to the fact that they are instructed 
to inflate the ears so as to equalize the pressure on both sides of the 
membrane. In this connection it must not be forgotten that there 
is always the natural atmospheric pressure of nearly 15 pounds on 
the outer surface of the drum. Xotwithstanding this, an eminent 
otologist has asserted that drum-heads have been lacerated by Po- 
litzers method. 

Professor Politzer says: "During thirteen years only fourteen 
cases of ruptured drum-heads are known. In the case of a normal 
membrana tympani a pressure of 45 to 60 pounds is required to 
cause rupture. In treatment, however, we apply only a pressure of 
about 8 pounds." If there were any fear of rupture, it could prob- 
ably be prevented by firmly pressing the tragus into the external 
meatus. 

As compared with the Yalsalvan method of autoinflation, the 
application of medicated nasal-tipped inflators as I have adapted them 
to the compressed-air apparatus makes an effective topical applica- 
tion of various medicaments possible without any active exertion on 
the part of the patient. In the Yalsalvan experiment there is no 
medication of the middle ears, but simply a mechanical effect of 
moderate pressure and a probable congestion resulting from the 
straining effort. A. Hartman has shown that 4 to 8 pounds' pressure 
by the Yalsalvan method is required to bulge forward a healthy 
drum-head. In numerous experiments the pressure averaged from 



34 COMPRESSED-AIR APPLIANCES AND THEIR USES. 

20 to 26 pounds in males and from 14 to 22 in females; but owing 
to swelling of the Eustachian tube or contained secretions this experi- 
ment often fails. 

The unwisdom of advising patients to practice the Valsalvan 
experiment has often been demonstrated by individuals who have 
come under my observation with a history of rapid failure of hearing 
owing to their habit of carrying the aurist's instructions to excess. 

Politzers method is far preferable. He says: "The pressure for 
the application of my method in practice varies, as a rule, between 
15 and 60 pounds. " 

A decided advantage to both patient and operator, in the adap- 
tation of the inflator to the compressed-air apparatus, lies in the 
fact that it renders it possible to treat most aural patients without 
the Eustachian catheter. 

The sponges of the inflator may be saturated with solutions of 
various remedies, and sprays of these medicines can be propelled 
through the nose and Eustachian tubes into the middle ears with 
ease and certainty in the majority of cases. This diminishes the 
danger of syphilitic infection and of irritation of the Eustachian 
orifices by the catheter. 

Gentle pressure will often accomplish this. Indeed, patients 
sometimes feel a spray enter the ear from an ordinary hand-atomizer, 
especially when the cheeks are distended. By turning on the current 
of air gently and gradually increasing it, the permeability of the 
tube may be re-established by a weak air-pressure more easily than 
by a sudden, forcible current. 

In practicing this method we have usually found the results 
most satisfactory when the patient assisted by inflating the cheeks 
and keeping the lips firmly closed. At the instant the closed nasal 
cavities become filled from the inflator the velum palati and base of 
the tongue press automatically upward and backward, completely 
closing the post-nasal space. 

When the effort to inflate the middle ears with air or lavolin 
jets alone fails, it can be made to succeed by placing 6 or 10 drops 
of sulphuric ether on the sponges in the inflator. The instant the 
ether enters the ears there is a decided sensation of coolness, followed 
by a glow of warmth. The stimulating effect can be seen also in the 
injected condition of the malleal plexus of vessels soon after the 
treatment. There are many instances in which the ears are more 
readily inflated during the act of swallowing. 






COMPRESSED-AIR APPLIANCES AND THEIR USES. 35 

It has been suggested that these forcible air-currents might 
convey discharges into the mastoid cells, but Michael has "proved 
that, especially with the application of strong currents of air, the 
secretion in the tympanic cavity is always propelled into the external 
meatus and not into the mastoid process." 

Occasionally one sees a case in which the current of air from 
the nasal-tipped innator fails to open the Eustachian tube. Probably 
the anterior lip of the orifice of the tube is pressed by the air more 
firmly than ever against its fellow, closing it like a valve. A case of 
tubal stenosis resisted 90 pounds with the nasal bulb, but 50 pounds' 
pressure carried a spray into his middle ears through the catheter. 

Treatment by the catheter is accomplished with the inflators 
already mentioned, the catheter-tip being substituted for the nasal 
bulb. The sprays are thrown through the catheter in interrupted 
jets without imparting painful movements to the catheter, which is 
well nigh impossible in the practice of inflation with the air-bag 
fitted with the hard-rubber tube which is inserted directly into the 
catheter, and without any intervening flexible tube, as the practice 
is in Vienna. 

Proper precaution should be taken to prevent dust from enter- 
ing the air-reservoir, although by the author's methods all air enter- 
ing the ears is filtered and medicated. 

Finally, these methods make the middle ears nearly as access- 
ible as the nose and throat for treatment with the various volatile 
remedies and sprays. 



CHAPTEE IV. 

METHODS OF PRODUCING AND USING COMPRESSED AIR. 

For a considerable time the author has been using a new kind 
of instrument called a dilator in connection with the compressed-air 
receiver, and the results have been so satisfactory that he has intxo- 





Fig. 19. — Dilators and combined air-reservoir and hand-pump. 



duced it into all of his clinics. This instrument and process of admin- 
istering aeriform fluids, although used by a few physicians since 
1888, appear to be little known. 

The dilator (Fig. 19) is not only different in construction, but 

(36) 



METHODS OF PRODUCING AND USING COMPRESSED AIR. 37 

also in operation, from the various kinds of spray-producers or nebu- 
lizing inhalers. The atomized product projected by it is not properly 
a spray or a vapor until it expands in the open air. It is so finely 
comminuted, indeed, that before it leaves the glass container the eye 
cannot discern it. After its exit from the nozzle it expands into a 
beautiful floating mass that is comparable to the most delicate un- 
dulating cloud. This fine nebula, which is produced and retained 
until administered under a higher pressure than hand-bulbs afford, 
may be impregnated with volatile or non-volatile medicaments. 

While making some experiments with the dilator I discovered 
that medicines three or four times stronger than patients would 
tolerate from the ordinary atomizers could be thrown into the re- 
spiratory passages, and even into the middle ear, without evoking any 
disagreeable symptoms. Xo less pressure than 20 pounds or even 
more should be employed in order to propel the nebula in sufficient 
volume and with enough force to dislodge tenacious secretions or 
crusts, to impress the nebulized remedies on the diseased surfaces, 
and to dilate the Eustachian tubes, innate the middle ears, or to open 
op stenosed bronchioles and occluded air-cells. While a pressure 
of 20 pounds may be sufficient, no injury has followed the em- 
ployment of a much higher pressure, as the excess escapes from 
the lips. 

One of my assistants, A. H. Andrews, has devised a combined 
coarse-spray producer and nebulizer which requires less pressure 
than other atomizers (Fig. 131). It is similar to the dilator. 

The combined pump and receiver is a very practical, durable, 
and economical form of apparatus where the pumping must be done 
by hand, it being comparatively easy to obtain 50 pounds. It is 
provided with a regulating meter-valve for controlling the pressure 
by the method described in a paper read by the author before the 
section on Otology and Laryngology of the American Medical Asso- 
ciation at Detroit in 1892. Any spray-producer or inflator can be 
attached to the cut-off and employed in the usual manner. 

Ear Treatment. 

The dilator can sometimes be substituted for my improved 
middle-ear inflator for projecting medicaments into the ear. With 
the latter we never use a stronger solution of the camphor-menthol 
than 3 per cent., while with the dilator we have medicated the tvm- 



38 



EAE TREATMENT WITH COMPRESSED AIR. 



panic cavity with the 10-per-cent. solution in lavolin without any 
unpleasant results. 

The nozzle is fitted into one nostril, while the other is held 
tightly closed, as in politzerization. The cheeks are fully distended 
with air, and the current is turned on from the compressed-air reser- 
voir. The instant the nebula, is felt to enter the ear the patient 
should raise his hand. Then the current is repeatedly interrupted 
by the cut-off so as to alternately fill the middle-ear with the nebula 
and allow it to escape. This produces not only inflation of the tube 







Fig. 20.— Compound hydraulic pump beneath the water-basin. 

and tympanum and motion in the ossicles and drum-head, but it 
medicates their mucous lining, on the same principle that we observe 
in medicating the mucous membrane of the eye, or the nose, or 
throat, when it is diseased. This, combined with the aid of the 
massage otoscope, provides an ideal treatment for dry catarrh of the 
tympanic cavity. 

When we reflect that middle-ear diseases are largely consequent 
upon an inflammatory action in the nose or throat, it becomes 
apparent how necessary it is to employ a thorough medicinal as 



COMPRESSED-AIR APPARATUS. <59 

well as mechanical treatment addressed to this section of the re- 
spiratory system; otherwise we cannot hope to effect a permanent 
improvement. 

In connection with the use of compressed air the question of 
air-pumps is an important one. In a city with water-works the com- 
pound hydraulic pump (Fig. .20) is effective, since it gives about double 




Fig. 21. — Single-acting' hydraulic pump. 



the amount of pressure obtained by the single-acting pump (Fig. 21). 
It requires to be cleaned and repaired occasionally, or it fails to afford 
the required pressure. The maximum of pressure to be had on a 
ground floor in Chicago, with a compound hydraulic pump, averages 
from 45 to 55 pounds, — an amount sufficient ordinarily for the 
aurist, for the air is constantly replenished. In the great modern 



40 



COMPRESSED-AIR APPARATUS. 



office buildings, compressed air is supplied to the tenants by means 
of Westinghoiise electric pumps, which are capable of affording any 
desirable pressure and quantity. In the country the surgeon must 
be satisfied with the hand-pumps (Fig. 22), unless he provides an 
elevated water-reservoir with sufficient head to furnish the pressure. 
The combined hand-pump and reservoir made by the Owens Brass 
and Copper Works, of Chicago, is very convenient (Fig. 19). The 




Fig. 22. — Rotary air-pump. 



pump is contained within the reservoir, which is supplied with an 
air-gauge, treatment-tube, and cut-off. The whole outfit weighs only 
fourteen pounds, which makes it conveniently portable. 

Another efficient apparatus is manufactured by the Cleveland 
Faucet Company. It is supplied with a modification of the author's 
air-meter that registers very accurately the pressure at the will of the 
operator and keeps it uniformly at any given pressure for which it 
is set (Fig. 23). Below 30 pounds it operates to a nicety. Pressure 
above this point can be used nearly to the amount contained in the 



POLITZERIZATION. 



41 



reservoir, but not with an equal accuracy of regulation. Another 
excellent modification of the Bishop air-regulator is made by the 
Owens Company, of Chicago. Regarding all of these apparatus the 
author speaks from experience in their use. 

Politzerization. — The aurist who is not provided with a com- 
pressed-air apparatus should possess a Politzer air-bag, and it is well 
to have one at hand to take the place of the air-pump should it fail 
to work. The Politzer bag (Fig. 24) is fitted with a nasal tip joined 
to the bag by eight inches of soft-rubber tube. One should also have 




Fig. 23. — Air-meter of improved pattern. 



a Buttle inrlator (Fig. 25) fitted with both nasal and catheter tips. 
In manipulating these the same rule should be observed as in the 
use of the author's compressed-air inflator (Fig. 26). The axis of 
the nasal bulb should be parallel to the plane of the floor of the 
nose. The object is to throw the column of air in the direction of 
the Eustachian orifice — not toward the nasal duct, through which 
the air is sometimes forced, nor toward the frontal sinus. The 
Politzer bag should be grasped with the larger end between the 
thumb and stronger fingers, so as to be able to exert the greatest 



42 POLITZERIZATION. 

force when it is necessary. The rubber tube intervening between 
the nasal or catheter tip and the bag takes up the motion imparted 
to the bag by the hand and prevents painful jerkings of the tips and 
the catheter. Especially in the use of the catheter this is an im- 




Fig. 24. — Politzer's air-bag. 

portant matter, and may prevent not only injury to the nose, but 
irritation or contusion of the Eustachian tube. The six- or eight- 
ounce bags are preferable to the larger sizes. The eight-ounce bag 
is the most useful for all purposes, and the rubber should be fresh, 
soft, and of the finest quality. 




Fig. 25 — Buttle's inflator. 

Catheterization. — The soft-silver catheters are the best (Fig. 
27). They can be easily bent to accommodate any irregularities in 
the nasal passages or in the vicinity of the Eustachian tubes. There 
are German silver catheters in our markets, but Albert H. Buck is 



CATHETERIZATION OF THE EUSTACHIAN TUBE. 43 

very correctly opposed to their use. since they are far inferior to the 
pure silver or hard-rubber catheters. It is desirable to have three sizes. 
As large a calibre as can be introduced without causing discomfort 
should be employed. To introduce the catheter, the beak of the in- 
strument is placed on the floor of the nose just posterior to the skin- 




Fig. 26. — The author's improved inflator. It is provided with a tip 
to fit into the Eustachian catheter. 



lined fossa at the entrance to the naris. At the first step, the handle 
is depressed so that the convexity of the beak will not hurt the arch 
of the nasal opening, but as soon as the beak rests on the floor the 
handle is raised and at the same time carried onward, bringing the 
main axis of the catheter to a. parallel with the floor. As the instru- 
ment enters the nose it must not be forgotten that the patient in- 
voluntarily moves his head backward. As soon as the beak touches 
the posterior wall of the pharynx we withdraw the catheter about 
one-eighth of an inch, rotate it so as to turn the beak outward and 
slightly upward, and its extremity should now be opposite the orifice 
of the tube. Then the hand is carried a little toward the median 
line, so as to bring the beak into the tubal opening (Figs. 28 and 
145). "With practice one can determine when the catheter rests in 



r* 




Fig. 27. — Eustachian catheter. 



the tube by the sense of fixation imparted to the instrument. Dur- 
ing this manipulation the ring on the proximal end of the catheter 
will indicate the position of the concavity or the convexity of the 
distal extremity. Xo force need be used. In cases of certain deform- 
ities of the inferior turbinated bodies and of the septum the catheter 



44 



CATHETERIZATION OF THE EUSTACHIAN TUBE. 



must be rotated through forty-five or ninety degrees, or more, before 
it can reach the pharynx. With the head thrown backward the weight 
of the silver catheter is often sufficient to carry it into the pharynx. 
The introduction can be facilitated by elevating the tip of the nose 
with the thumb of the left hand while the fingers rest on the bridge 
of the nose or on the forehead. 

However, with the improved compressed-air appliances at hand 




Fig. 28. — Vertical section of the naso-pharynx with the catheter intro- 
duced into the Eustachian tube, a, inferior turbinated bone; b, middle 
turbinated bone; c, superior turbinated bone; d, hard palate; e, velum 
palati; f, posterior pharyngeal wall; g, Rosenmiiller's cavity; h, poste- 
rior lip of the orifice of the Eustachian tube. The frontal sinuses are 
shown above the line c. (After Politzer.) 



it is rarely necessary to resort to the catheter except for sclerosis. It 
is destined to pass out of vogue to a certain extent, for the reason 
that air, volatile medicaments, and even nuid-vaselin sprays can be 
successfully projected into the middle ears by means of the improved 
inflator (Fig. 26) adapted to the compressed-air apparatus. To the 
average patient this is a happy culmination of the inventor's efforts, 
for it averts positive suffering, the possibility of infection and Of irri- 



CATHETERIZATION OF THE EUSTACHIAN TUBE. 



45 



tative effects, and incidentally reduces the amount of skill required 
for treatment. It may be desirable to employ the catheter to inject 
liquids into the middle ear, or when the inflation must be limited to 




Fig. 29. — Fixation of the catheter with the left hand. Catheterization 
as it is practiced in Vienna. (After Politzer.) 

one ear, but even in the latter case we may generally accomplish this 
end with the improved inflator by closing the opposite ear with the 
patient's finger during inflation. However, we do not desire to be 
understood as having discarded entirely the use of the catheter after 
many years of experience with it. 

When occasion necessitates the use of the catheter (Fig. 29), the 
air-pressure must be greatly reduced, for, as Huntington Eichards ob- 
serves: "By it greater power is exerted, and it is more strictly limited 




Fig. 30. — Toynhee's auscnltation-tube. 

to a single ear." If more than 1 or 2 atmospheres (15 to 30 pounds) 
be used with the catheter-beak not properly adjusted, there is a pos- 
sibility of forcing the air into the submucous tissues and producing 



46 AUSCULTATION OP THE EUSTACHIAN TUBE. 

a dangerous emphysema. We have never seen any such results from 
this cause, but three deaths are recorded. Thomas Faith has re- 
cently reported to me a case of emphysema of such character, with 
recovery. 

An aid in both diagnosis and treatment lies in Toynbee's aus- 
cultation-tube (Fig. 30). One end of the tube should terminate in 
a white tip and the other in a black one. By inserting the white tip 
in the operator's ear while the black one rests snugly in the patient's 
meatus, any sound produced in the ear of the patient is perceived 
by the surgeon. Thus, when air is forced through the Eustachian 
tube and impinges against the inner surface of the membrana tym- 
pani, the resulting sound is conveyed along the continuous column 
of air in the patient's external canal, the rubber tube, and the sur- 
geons auditory meatus to his drum. It is not difficult, then, to dis- 
tinguish between the free, breezy puff of air through a patulous Eu- 
stachian tube and the high-pitched, squeaking sound occasioned by a 
stenosis. 



CHAPTER V. 
DISEASES OF THE EXTERNAL EAK. 

The Auricle. 

There are certain injuries and diseases of the auricle that are 
not properly classed as ear affections, the treatment of which is con- 
ducted on general principles sufficiently amplified in works on sur- 
gery. Such affections and injuries as would not require treatment 
differing from that demanded by the same conditions in other parts 
of the body will not greatly encumber our pages. 

diseases of the auricle. 

Frost-bite. — The symptoms of this condition are so familiar that 
a description would be superfluous. The chief object to be accom- 
plished is to prevent a sudden disturbance of the circulation in the 
skin, by insuring a very gradual return to the normal temperature. 
This is best secured by the application of continuous cold by means 
of snow inclosed in a handkerchief or by an ice-bag (Fig. 83) to the 
auricle after padding the post-auricular space for support. As the 
crushed ice melts, the temperature of the bag gradually rises until 
the ice becomes water, and the temperature of the water slowly arrives 
at the normal bodily temperature. Then the auricle should be dressed 
with a thick covering of an ointment consisting of equal parts of 
benzoinated oxide-of-zinc and carbolic-acid ointments. The parts 
should be protected with gauze or absorbent cotton. 

Eczema. — This skin disease is so common and so well described 
in general works that we may best confine ourselves to the subject 
of treatment. Eczema is usually associated with a chronic suppura- 
tive inflammation of the middle ear, and is a result of that disease. 
The external canal is likely to be involved at the same time. The 
acrid, irritating discharges set up the dermatitis wherever they spread, 
even to the neck, side of the face, and head. So long as these dis- 
charges continue to bathe the skin, just so long will the treatment 
of the eczema prove unavailing. The ear must be so cleansed and 

(47) 



48 LUPUS OF THE EAR. 

kept free from pus, by constant vigilance and the treatment out- 
lined in the chapter on suppuration, that the discharges cease to 
reach the auricle and surrounding parts. If there are crusts, they 
are softened and removed by means of Castile soap and warm water. 
When the surface is thoroughly clean it is covered thickly with ben- 
zoinated oxide-of-zinc ointment, which must be strictly fresh and 
prepared with the purest zinc oxide. This is retained in place by a 
gauze or fine-linen dressing. In case of great itching or burning the 
carbolic-acid ointment is added to the zinc ointment in the propor- 
tion of one-fourth or one-half carbolic ointment. This acts not only 
as an antiseptic, but as a grateful local anaesthetic also. Among the 
most prompt and effective remedies to relieve the pruritus are resinol 
and epidermol. In obstinate cases a 3-per-cent. salicylic-acid oint- 
ment of lanolin has proven rapidly curative, and the same may be 
said of the yellow-oxide-of-mercury ointment, 5 grains to the ounce of 
vaselin (1 per cent.). 

When the raw-appearing surface rapidly exudes drops of serum, 
weeping eczema, it should be gently dried by merely touching with 
absorbent cotton without any friction, and then covered with aristol 
or nosophen. Prompt drying and cicatrization follow. General treat- 
ment may be needed for an impoverished condition of the system, 
and, if so, Fowlers solution of arsenic is a valuable addition to in- 
ternal medication. 

Lupus. — Lupus vulgaris generally attacks the auricle second- 
arily to its existence in the face. Yet Ave have seen it confined to the 
auricle and external canal following, like eczema, a chronic suppura- 
tion of the middle ear. Brown tubercles about the size of a pin-head 
or a small pea form in the concha, about the mouth of the auditory 
canal, or in other parts of the auricle. They may be covered with 
brown crusts or scales. Sometimes they shrink up so as to form cic- 
atrices, which, in turn, may break out later. Lupus exulcerans ap- 
pears in the form of ulcers covered with brown crusts, underneath 
which is a spongy, moist, or bleeding surface. Nodules may be seen 
in the periphery of the ulcers and aid materially in making a certain 
diagnosis. There is no considerable pain in the early stages, as a 
rule, nor intense itching as in eczema. The skin is of a darker hue 
than in the latter disease. A case in my practice, of a lawyer and 
prominent politician of 60 years, was secondary to a chronic suppura- 
tion of the middle ear. After stopping the suppuration the ulcers in 
the meatus and on the auricle healed under aristol. After three years, 



GANGRENE OF THE EAR. 



49 



however, the disease again attacked the auricle, during his absence in 
the West, and destroyed it. (Since writing the above he has died.) 
All the diseased tissue is best removed by the curette, the gal- 
vanocautery, nitrate-of-silver stick, acetic acid, etc., under cocaine 
anaesthesia, and the wound is dressed with aristol or iodoform cov- 
ered with dry iodoform gauze. The prognosis must be guarded, on 
account of the strong tendency to recurrence. 




Fig. 31. — Gangrene of the ear; mastoid operation. 



Gangrene. — Gangrene of the auricle is a very rare disease. It 
may arise without any assignable cause; but any condition that viti- 
ates the blood and lowers the vitality and powers of resistance in the 
presence of a local exciting cause, such as intense cold, pressure, acrid 
discharges, burns, destructive chemicals, etc., predisposes to this 
necrotic process. The author has seen one case only. This applied 
at his clinic at the Illinois Medical College with the following his- 
tory: A boy, 2 years old, had been an inmate of an orphan-asylum 



50 CARCINOMA OF THE EAR. 

five months. Two months before we saw him a suppuration of the 
right ear began. Five clays before he was admitted to the hospital 
the skin covering the concha turned black and emitted a foul stench. 
Both sides of the auricle were necrotic, as well as the adjoining skin 
of the mastoid process. The necrotic tissue was cut away and the 
bone was found involved, necessitating a mastoid operation (Fig. 
31). After the operation the child, in common with other members 
of his family, had measles. His brother died, and our patient was 
attacked with pneumonia, from which he died. The autopsy showed 
pulmonary tuberculosis. 

If gangrene is seen early enough, warmth should be applied to 
stimulate the circulation until the necrotic tissue separates from the 
healthy; otherwise operative measures as indicated above are called 
for. 

Carcinoma. — This more frequently arises on the auricle or in 
the external meatus than in the middle ear or mastoid process. It 
begins with a sensation of irritation or itching, which the patient 
increases by persistent efforts to relieve. The development is slow at 
first and rapid afterward. The irritation is supplanted by ulceration, 
which, however, is easily distinguished from other similar conditions. 
While in the lupus exulcerans the ulcer is deep, excoriating, and 
penetrating, in carcinoma the ulcerating surface is raised above the 
surrounding tissues, exuberant granulations often projecting to a con- 
siderable degree. If the lateral cervical glands become infiltrated the 
diagnosis is more certain, but they are slow to participate. 

The ulceration may extend to the tympanic cavity, labyrinth, 
and cranial cavity, producing facial paralysis, haemorrhages, menin- 
gitis, brain-abscess, or thrombosis, and, after great suffering, death. 
The treatment consists in complete extirpation of the diseased tissue 
when possible, the knife penetrating beyond the disease into the sur- 
rounding healthy tissue. If the auricle is extensively involved it 
should be amputated, and if the cervical glands are affected they 
must be excised at the same time. Should it be necessary to invade 
the external meatus, a plastic operation may possibly preserve its 
patency, which is important on account of the hearing. After-treat- 
ment is the same as for lupus. For treatment with alcoholic injec- 
tions see treatment of carcinoma of the pharynx. 

Perichondritis. — This is not a frequent disease, but early treat- 
ment is important to prevent deformity. In the early stage there 
occurs a swelling of a part or the whole of the auricle, with a dusky- 



BLOOD-TUMOR OF THE AURICLE. 51 

red surface, accompanied by heat and pain. We have seen the auricle 
increased to an enormous size by the effusion of a syrup-like fluid 
between the cartilage and the perichondrium. 

Treatment consists first in the application of cold by means of 
an ice-bag (Fig. 83). If there is great swelling with fluctuation it 
must be incised, the fluid pressed out, and the cavity irrigated with 
antiseptic solutions. AYe have obtained the best results from inject- 
ing equal parts of tincture of iodine and water or alcohol, and apply- 
ing pressure with cotton and a bandage. 

Hsematoma. — Othematoma is an effusion of blood between the 
cartilage and the perichondrium. It rarely arises spontaneously, but 
is generally the result of traumatism. It occurs suddenly after a blow 
on the ear or pulling the auricle. It is a rather frequent occurrence 
in the mentally defective, and possibly indicates a disease of the base 
of the brain. Brown-Sequard has shown that section of the resti- 
form body in animals is followed by this disease. The appearance 
of the tumor is accompanied by heat and pain. It nearly always oc- 
cupies the anterior aspect of the auricle, and may cover a large por- 
tion of that surface. The natural outlines are obliterated, and in 
their place is a fluctuating, pale, bulging tumor. It may rupture 
spontaneously or suppurate, or in rare instances it disappears. Dur- 
ing the first, or inflammatory, stage, when there are heat and pain, 
the constant application of cold is indicated (Fig. 83). If an ice-bag 
is not obtainable, a bladder can be filled with ice or snow as a sub- 
stitute. If the swelling does not diminish, it must be incised, in one 
of the natural folds to prevent disfiguration, and emptied of its con- 
tents. Most satisfactory results have followed washing out the cavity 
with a 5-per-cent. aqueous solution of carbolic acid, insufflating with 
aristol, and binding it with an absorbent-cotton compress. Eandall 
opens the sac, curettes it, rubs with iodine glycerite, packs with iodo- 
form gauze, and covers it with a pressure bandage. 

In this connection it is our duty to condemn in the strongest 
terms the brutal practice of pulling and boxing the ears of children 
indulged in by ignorant parents and teachers. The author has seen 
many cases of deformities, ruptured drum-heads, abscesses, and deaf- 
ness resulting from this inhuman habit. 

Cystoma. — Cystoma is a tumefaction usually found on the ante- 
rior aspect of the auricle. Its appearance is similar to the blood-tumor 
-already described, but it contains, instead of blood, a serous fluid, 
which is sometimes of a syrupy consistence and appearance. It arises 



52 DEFORMITIES OF THE AURICLE. 

suddenly from an unknown cause, without a previous injury or in- 
flammation. The treatment is the same as for hematoma, — incision,, 
etc. 

Intertrigo. — xAn excoriated condition of the skin on the adjoin- 
ing surfaces of the auricle and mastoid process is of frequent occur- 
rence among children of the poor. It may be due to an impoverished 
condition of the blood, but is more likely to be caused by uncleanli- 
ness and the harmful habit of binding the ears down against the head 
by close-fitting caps. The skin denuded of its cuticle presents a red,, 
raw, moist appearance, but it is smooth and without thickening, in 
this respect differing from eczema, which may be ingrafted upon it. 
The trouble is aggravated by the efforts of the child to relieve the 
intense itching by scratching. The treatment is similar to that for 
eczema, except that dry applications are indicated, as in the weeping 
form of eczema. Powders are preferable, and of these aristol is suffi- 
cient. The binding caps must be interdicted and the irritated sur- 
faces kept apart. 

Miscellaneous. — Herpes, pemphigus, and syphilis of the auricle 
are very infrequent lesions that differ in no way from the same affec- 
tions of other parts of the cutaneous system and require no different 
treatment. Not being diseases peculiar to the ear, their description 
will be omitted here. 

DEFORMITIES OF THE AURICLE. 

Arrested and excessive development of the auricle in relation to^ 
degeneration have been made the subject of extensive investigation 
by E. S. Talbot, of Chicago; Spitzka, and others; but the discussion 
of this phase of the subject lies without the province of this book. 
Talbot's illustrated article, from which Fig. 32 is taken, may be found 
in the Journal of the American Medical Association for January 11,. 
1896. 

Auricular deformities may be divided for convenience into con- 
genital and acquired. Congenital deformities may be classified as 
correctable and irremediable. Acquired deformities fall under two 
headings: those resulting from disease and those from injuries. 

Hypertrophied Auricle. — The most common defect is the large, 
flattened, wing-like ear that stands out conspicuously from the side of 
the head (Fig. 32). This ear-mark serves as a butt of jest for the 
child's companions, and makes life a burden to the bearer. Its ex- 
aggerated prominence suggests its prototype among the lower animals,. 



HYPEKTEOPHIED AURICLE. 



53 



the mule-ear. The natural surface inequalities are diminished, the 
border of the helix is often thin and expanded, and the whole flaring 
pinna appears as if it had been subjected to constant pulling or 
pressure. 

While a large percentage of these cases are congenital, that bar- 
barous mode of petty punishment — pulling the ears — may account 
for a certain amount of this deformity. We have been led to this 
conclusion by information elicited in many instances. The pressure 
produced by the tight caps so much in vogue with some people may 
be a factor. 

The treatment is operative. The author has proceeded in two 
ways: by reducing the actual size of the auricle, and by effecting a 




Fig. 32. — Hypertrophied auricle. 



corrective amount of adhesion between the auricle and the mastoid 
process. The first operation is done by removing an elliptical section 
of the cartilaginous frame-work and the corresponding 'integument 
on the posterior surface and bringing the edges of the wound together 
with sutures including the cartilage. The long diameter of the 
ellipse is, of course, vertical. The cartilage must be dissected out 
without penetrating the skin of the anterior surface. By making 
accurate measurements and marking the size and shape of the section 
to be removed, the result will be satisfactory. The auricle is then to 
be dressed with aristol, antiseptic gauze, and the net bandage. This 
bandage is made of white mosquito-netting, moistened through just 
before applying, and it dries in place somewhat like the plaster band- 
age. Union by first intention is had and the stitches are removed as 
soon as the adhesion is firm. This method is superior to the removal 



54: SCEOLL-EAK AND ASSOCIATED DEFORMITIES. 

of the skin alone, in which case the resilience of the cartilage tends 
to tear out the sutures or bulge forward the anterior surface unduly. 

The second method is easier to practice, and I have given it 
preference for a number of years. The auricle is pressed against the 
side of the head in such a way as to give it in every part a little less 
projection than it ought to have. Now the line of junction is marked 
throughout its whole extent on both auricle and head. The section 
of skin included within these lines is dissected out in a thin layer so 
as to leave a denuded surface; the edges of the wound are approxi- 
mated and sutured with the stitches close together and penetrating 
the subcutaneous tissues. The dressing and subsequent treatment are 
the same as after the first operation. 

This corrects a most unsightly deformity and may result in a 
beneficial influence on the temper and happiness of the patient for 
the remainder of his life. So far as we have been able to learn, this 
method of operating had not been practiced previously to its intro- 
duction by the author. 

Scroll-ear and Associated Deformities. — There is a deformity of 
the auricle in which the border of the helix turns forward and down- 
ward in a scroll-like roll. In such cases as I have seen the auricle is 
diminutive in size and does not present favorable conditions for an 
operation. In certain instances this condition amounts almost to 
obliteration of the pinna, and the auditory canal is absent. To illus- 
trate, we will cite one of the cases reported by the writer to the Tenth 
International Medical Congress held in Berlin: — 

A girl, 8 weeks old, was brought to my clinic October 10, 1885. 
There was a congenital deformity of one auricle and absence of the 
external auditory meatus of the same ear. The auricle was rudi- 
mentary and doubled forward upon itself. It appeared shrunken and 
pinched, and had a large, hard nodule and several indentations in that 
part of the helix that corresponds to the key-stone of an arch. 

It is interesting to note, in this connection, that the mother at- 
tributed the deformity of the auricle to the fact that, about the fifth 
month of gestation, her elder child bit the mother's ear severely, at 
just that point that corresponds to the greatest auricular deformity 
in the baby. 

At the point where the canal ought to have been there was a 
depression or cul-de-sac that yielded to pressure, and imparted to the 
touch an impression as if there were an opening in the bone beneath. 

Four months later careful tests led us to believe that the child 



ANOMALIES OF THE EXTERNAL EAR. OD 

could hear with that ear. I operated to correct, as far as possible, 
the deformity of the auricle, and to ascertain if there were any bony 
meatus. On cutting down into the cul-de-sac where the canal should 
have been, we found nothing but a depression in the bone. Xo bony 
canal could be found, and it did not appear that further operative in- 
terference would be justifiable. However, a sufficient opening was 
maintained to give quite a respectable appearance of an external 
meatus. 

Virchow^s Archives says: "Congenital anomalies of the external 
ear and its neighborhood are to be referred to early disturbances in 
the closure of the first branchial cleft, and are often associated with 
fistulas of the other branchial clefts, cleft palate, and other forms of 
arrest of development in the facial bones, — as, for instance, with uni- 
lateral atrophy of the face." 

Certain acquired deformities have already been noticed in con- 
nection with the diseases that produce them, — perichondritis, etc. 
Treatment can hardly avail to remedy them. Those resulting from 
injuries must be treated on general surgical principles, with care to 
prevent any closure of the auditory canal. The latter subject will 
be presented in the following chapter. 



CHAPTEK VI. 

DISEASES OF THE EXTERNAL AUDITORY CAXAL. 

Inspissated and Impacted Cerumen. 

Impacted wax is a common condition that may give rise to 
serious results. It is really a symptom of disease, and often is provo- 
cative of other pathological manifestations. Eecurring hyperemia or 
eczema of the external canal may excite the ceruminous glands to 
hypersecretion, and anomalies of the canal may prevent the natural 
process of elimination of the cerumen; so that for these two reasons 
it becomes dried and impacted. With the movements of the lower 
jaw, corresponding motion is imparted to the cartilaginous portion of 
the canal, which has the effect of working the accumulations of wax 
outward; but, when the mouth of the canal is very narrow and when 
exostosis or other mechanical obstructions occur, they prevent the out- 
ward movement of the secretion, and it stops up the canal effectually. 
Patients often contribute to this impacting process by their efforts to 
cleanse the canal with towels, etc., at the bath. The middle ear may 
not be involved in the diseased process, or both parts may participate 
in trophoneurotic changes due to central causes. There may be, 
moreover, a simple desquamative inflammation with an abundant ex- 
foliation of the epidermis. In these cases the ceruminous plugs con- 
sist of the fatty secretion, epithelial scales, hairs, etc., which are often 
horn-like in their hardness. 

Symptomatology. — The hearing may not be perceptibly dimin- 
ished, providing the middle ear is in its integrity and the plug does 
not completely fill the lumen of the canal; but sudden impairment 
of hearing and a stuffy sensation in the ear, with confusion, may 
supervene directly after a bath or profuse perspiring, occasioned by 
absorption of moisture and swelling in the plug. On the other hand, 
there is a gradual diminution of the hearing-power going on for years, 
and scarcely observed by the patient until his friends call his atten- 
tion to it. Tinnitus aurium often occurs, and, with complete blocking 
of the canal, intense subjective noises; autophony, or a hollow sound 
of one's own voice; neuralgia of the ear or the temporal and supra- 
orbital regions; numbness about the ear and side of the face, reflex 

(56) 



INSPISSATED AXD IMPACTED CERUMEN. J. 

cough of a spasmodic character, and mental dullness. Children are 
'often chided for inattention or inaptitude when they are the unfortu- 
nate victims of such an ear disease. In the latter case both ears will 
probably be found to be affected. Impacted cerumen gives rise to 
even more serious symptoms, for the plug, which is, in effect, a for- 
eign body, works inward until it impinges upon the drum-head, caus- 
ing perforation or intralabyrinthal pressure, vertigo, and epilepti- 
form seizures. After a suppuration of the middle ear has ceased I 
have found these large plugs blocking the exit for pus when a fresh 
cold has set up another suppurative inflammation. In such cases the 
pus may burrow inward and fill the mastoid cells, and even seek the 
cranial cavity before it can dislodge or penetrate these stone-like 
plugs. Their presence sometimes is sufficient to cause absorption of 
the canal-walls and an immense increase in the size of the canal. 
After their removal the skin beneath is often inflamed and appears 
more like mucous membrane than healthy integument. 

Diagnosis. — The diagnosis is easily made on inspection of the 
canal, for the dark-brown or black mass is plainly visible, obstructing 
a view of the drum-head. 

Prognosis. — The prognosis depends upon the condition of the 
middle ear and labyrinth. If they are healthy the hearing will be 
restored and the subjective symptoms removed with the extraction of 
the cerumen. 

Treatment.— The treatment consists (1) in the complete removal 
of the plug and (2) in remedies addressed to any pathological condi- 
tion revealed by its extraction. If one is adept in the manipulation 
of ear instruments he can dextrously pull out the plug with the little 
lever found in the middle-ear set of instruments (Fig. 70). It should 
be passed into the canal with the lever horizontal, next the roof, and 
carried far enough so that when the lever is turned downward it will 
imbed itself in the cerumen. The latter may be so hard that quite a 
considerable pressure must be exerted to penetrate it, or it may be 
so soft that only a part, instead of the whole plug, will glide out with 
the lever when traction is exerted. Care should be taken not to touch 
the drum-head or produce any abrasion of the canal-wall with the 
lever. Those avIio are not practiced in ear-work had far better use 
the syringe. The continuous-flow rubber syringe with hand-bulb to 
regulate the pressure is the best. The glass syringes usually sold un- 
der the name of ear-syringes are of no account whatever for this pur- 
pose. The hard-rubber piston syringe is made for the ear with a 



58 DIFFUSE INFLAMMATION OF THE EXTERNAL MEATUS. 

flange to prevent its being introduced too far, but patients are likely 
to insert the nozzle so far that the flange stops up the canal opening, 
thus forcing the plug farther inward, or, when the plug is out, exert- 
ing undue pressure on the drum-membrane or even rupturing it. The 
Davidson alpha or omega syringe (Fig. 33) has proved even more 
effective than the fountain-irrigator. The stream should be thrown 
so as to enter any space that may be seen between the canal-wall and 
the cerumen, rather than against the centre of the plug. As much 
force should be employed as the patient can bear with comfort, and 
without producing dizziness; and the water must be as warm as can 
be easily borne, and a quart or more may be necessary at a sitting. 
The emulsifying and disintegration of the ceruminous mass can be 
much facilitated by preceding the use of the syringe with an instilla- 
tion of a 4-per-cent. solution of bicarbonate of sodium in glycerin 




Fig. 33. — Alpha syringe. 

and water, equal parts. The ear should be filled with this fluid 
warmed, several times during the clay, allowing it to remain a quarter 
of an hour; then the mass breaks up readily and washes out with 
the injections. The canal should afterward be dried, smeared with 
warm vaselin, and protected for a few days with clean cotton. Any 
dermatitis should be treated according to the principles laid down 
under the following heading. 

Diffuse Inflammation of the External Meatus. 

Diffuse inflammation may be acute or chronic in character and 
may include the whole extent of the canal, although it is usually con- 
fined either to the osseous or to the cartilaginous portion. In my 
experience it more often has affected only that part of the meatus 
that adjoins the drum-membrane, and frequently it was limited to 
the superior half of the canal and invaded the membrana flaccida. 



DIFFUSE INFLAMMATION OF THE EXTERNAL MEATUS. 59 

Pathology. — If seen early the canal-wall presents a bright-red 
and smooth aspect. When the inflammation becomes intense and in- 
filtration of the integument causes it to swell, the lumen of the canal 
is so encroached upon as to make an examination of the drum-mem- 
brane difficult or impossible. The walls then lie in contact and even 
press upon each other; so that introduction of the smallest funnel 
is impracticable. When the membrana tympani is involved and can 
be seen, it may look red and swollen and the hammer-handle may be 
wholly invisible. A white coating of epidermis is frequently found 
lying loosely in the canal, and can be easily detached and removed 
in casts. In an advanced stage ulceration and granulations are found. 

Etiology. — The common habit of working at the ears with ear- 
spoons, hair-pins, common pins, matches, and other hard substances 
is a prolific cause of inflammation of the canal. Instilling oil that 
becomes rancid, foreign bodies, and vegetable parasites act as ex- 
citing causes. 

Symptomatology. — In the first stage, or hyperemia, there may 
be no pain or impairment of function, and the patient remains un- 
conscious of any unusual condition except for the itching. His at- 
tempts to relieve this only serve to increase the irritation, and, as the 
disease progresses, pain of a severe character is developed. The move- 
ments of the jaw and pressure about the ear aggravate the pain. 
With the occurrence of profuse transudation the hearing is dulled, 
and tinnitus and even vertigo may ensue. The more copious the 
exudation, the greater the stenosis and impairment of hearing. In 
very old cases the canal is found full of an offensive, thick, and greasy 
secretion. 

Diagnosis. — The diagnosis is not easy to make when the stenosis 
is great. It may be impossible to differentiate between an affection 
of the canal alone and one affecting both the canal and middle ear. 
A microscopical examination of the exfoliated epidermis for micro- 
cocci and vegetable fungi may clear up the diagnosis. 

Prognosis. — This depends upon the extent of the inflammatory 
process. It may invade the tympanic cavity and produce suppuration. 
It may extend to the bony walls and even to the mastoid cells and 
cranial cavity, but such results are rare. The lumen of the meatus 
may be permanently contracted or obstructed by adhesive processes. 
But the usual course under proper treatment is favorable. 

Treatment. — If the inflammation is very active and painful and 
the stenosis complete, an ice-bag (Fig. 83) should be applied. Ab- 



60 FURTJJs"CULOSIS. 

straction of blood by leeches may give relief, two being applied in 
front of the tragus. If the canal is sufficiently open to permit of 
washing it out, a 3-per-cent. hot solution of carbolic acid should be 
used until the canal is thoroughly cleansed. Then it should be dried 
with cotton without friction, and covered with a coating of aristol 
by means of a small powder-blower (Fig. 34). If this does not stop 
the secretion in a few days, nosophen or the fine boric powder should 
be substituted. 

FURUNCULOSIS. 

Synonyms. — Furuncle; boil; follicular or circumscribed inflam- 
mation of the external meatus. 

Pathology. — Furuncles are mostly limited to the cartilaginous 
portion, and most frequently to the posterior or anterior wall of the 




Fig. 34. — Author's small powder-blower for the ear. It can be 
operated by a small rubber bulb also. 

auditory canal. Although they may be secondary to a middle-ear 
inflammation, they are frequently idiopathic in character. Furuncles 
appear singly, in groups, or in successive crops, and probably are due 
to the staphylococcus pyogenes, aureus, and albus entering the hair- 
follicle or sebaceous gland, or to some trophic change in the nervous 
supply of the meatus. 

Etiology. — Any irritation of the canal predisposes to furuncle: 
foreign bodies, irritating instillations, ear-spoons, matches, discharges 
from the tympanic cavity, too frequent syringing, and vegetable para- 
sites. The same may be said of a general impairment of health, dia- 
betes, anaemia, and dyspepsia. 

Symptomatology. — The onset of the attack is attended with a 
sense of fullness or itching, followed by tenderness on touch, pains of 



FURU2n t CUL0SIS. 61 

a throbbing character, and, as the swelling increases, impaired hear- 
ing and subjective noises. The pain becomes intense for a day or two 
and subsides on the rupturing of the boil. Movements of the jaw 
increase the pain to such an extent that mastication is out of the 
question. When the furuncle is located on the anterior wall, the 
tragus may become red, swollen, prominent, and sensitive; when it 
is on the back wall, the swelling may be sufficient to protrude the 
auricle and simulate the appearance of mastoid periostitis. Occasion- 
ally the cervical glands, and the lymphatic glands over the mastoid 
process, when they are present, become infiltrated. For the first two 
or three days the fever, headache, and furred tongue denote a gen- 
eral systemic disturbance. 

Diagnosis. — This is not difficult on careful inspection with brill- 
iant illumination. This disease is not likely to be confounded with 
any other, when we consider the prominent symptoms. The boils 
are easily detected with the probe. 

Prognosis. — The disease usually runs its course in about a week. 
and unless successive crops occur, or unless the general health is im- 
paired, the trouble is over. But it should not be forgotten that in 
certain instances the inflammation has invaded the tympanum, the 
mastoid, and even the cranial cavity. 

Treatment. — The first indication is to allay pain, if there be any, 
for which bromidia internally and cocaine locally are effective, the 
former in teaspoonful doses in water every half-hour or hour for an 
adult until pain ceases, and the latter in a very warm, 10-per-cent. 
solution. As soon as the pain is relieved we should cleanse the meatus 
with hydrozone (dioxide of hydrogen, or peroxide) comfortably warm. 
It can be warmed to a little above blood-heat (105° F.) without im- 
pairing its effectiveness. Its effervescent action washes out the canaL 
and its bactericidal property strikes at the root of the trouble. After 
cleansing, a 20-per-cent. solution of camphor-menthol on cotton ex- 
erts a comforting and curative influence. It is to some degree a local 
anaesthetic, antiseptic, and a constrictor of the capillary blood-vessels. 
A 12-per-cent. solution of carbolic acid in glycerin acts similarly. 
They are applied, like the cocaine, on a cotton tampon. As soon as 
a point of distinct fluctuation can be made out, it should be incised 
deeply through the centre, under cocaine, and pressure exerted about 
the base to express all pus or necrotic tissue. After once thoroughly 
cleansing the canal, it is important to keep the skin as dry as pos- 
sible in and around the meatus, on the same principle that guides us 



62 PARASITIC INFLAMMATION OF THE EXTERNAL MEATUS. 

in the treatment of suppuration of the middle ear. Thomas Barr has 
obtained marked benefit from the ointment containing 4 grains of 
iodoform or boracic acid, and 2 grains of menthol in a drachm of 
vaselin. This is smeared on cotton pledgets and placed so as to pro- 
duce a little pressure on the boil, but the plugs should be changed 
as often as the accumulation of the discharge requires. 

Subsequent treatment consists in the application of a small 
amount of yellow-oxide-of-mercury ointment, 5 grains to the ounce; 
salicylic-acid ointment, 3-per-cent.; or carbolic-acid ointment. Proper 
treatment is addressed to the general health. Sulphide of calcium is 
credited with the power of aborting or modifying the disease. 

Parasitic Inflammation of the External Meatus. 

Synonyms. — Mycosis; otomycosis; mycomyringitis; aspergillus; 
myringitis parasitica; ear-mold; aural fungi. 

Pathology. — Vegetable parasites in large variety are found in 
the auditory canal, but it is beyond the scope of this work to give a 
detailed description of the microscopical appearances of these fungi. 
For an extended study of this subject the reader is referred to- Bur- 
nett's exhaustive work. The most frequent varieties are the dark- 
brown aspergillus, or nigricans; the yellow, or navescens; the green, 
or glaucus; and the grayish black, or fumigatis. When these para- 
sites once find lodgment in the ear they multiply rapidly. This usu- 
ally begins upon the drum-head, and the growth and the resulting 
inflammation extend outward until the whole meatus may be involved. 
These cases are not often seen until they are so far advanced that the 
condition is generally one of complete covering of the drum-mem- 
brane and meatus with the mold. On removing the growth, which I 
have peeled out in a complete cast of the canal, the skin is red and 
raw in appearance, as though robbed of its epidermis. 

Etiology. — A damp atmosphere favors the growth of these para- 
sites. The middle-aged and poor are the most frequently attacked. 
The common use of oils by the laity predisposes to. this disease, as 
does any decomposing secretion or substance in the ear. 

Symptomatology. — Ear-mold may exist for a long time without 
the patient becoming aware of its presence, but when an active in- 
flammation supervenes decisive symptoms develop. At first there is 
only an itching or irritation or feeling of fullness, followed by pain, 
subjective noises, and diminished hearing. In my experience there 






PARASITIC INFLAMMATION OF THE EXTERNAL MEATUS. Go 

is rarely a discharge except when the disease is secondary to a suppu- 
ration of the tympanic cavity; but if the inflammatory action is severe 
a serous exudation occurs. Inspection shows in the black variety 
what is easily mistaken for a long-standing plug of inspissated ceru- 
men were it not that the surface of the obstruction has a velvety or 
coal-dust appearance. In case of the yellow aspergillus, the parts look 
as though they had been sprinkled with finely-powdered mustard or 
yellow pollen. On removing the false membrane formed by the mold, 
its surface next the skin is of a dirty, grayish-white color. I have 
found this growth ingrafted on ceruminous plugs which required con- 
siderable time and care in removing. After their removal there was 
revealed not only the characteristic inflammatory condition, but an 
enormous distension of the meatus, due to pressure and the absorption 
of the canal-Y\ T alls. 

Diagnosis. — Having the appearances described in mind, this is 
not difficult under good illumination, but a microscopical examina- 
tion will set all doubts at rest. 

Prognosis. — This disease is rapidly amenable to the following 
method of treatment, a few days or weeks, at most, effecting a cure. 

Treatment. — The ear should be syringed with a quite warm solu- 
tion of bichloride of mercury in water, 1 to 5000. Enough should be 
used to dislodge and remove all cerumen, discharges, false membrane, 
and debris that the ear may contain. The class of people in whom 
the mold is found work or live in a dirty atmosphere, and the ears 
are a label of this fact. After absolute cleanliness has been effected, 
the meatus should be filled with warm hydrozone (dioxide of hydro- 
gen, peroxide, H 2 2 ). This is left as long as it effervesces, then re- 
moved, and the canal is gently dried with absorbent cotton. Xow 
the meatus is filled with a 12-per-cent. solution of carbolic acid in 
glycerin for ten minutes; then this is removed and a saturated solu- 
tion of iodoform in alcohol is substituted. The carbolic acid does not 
corrode the tissues in this combination, but acts as an antiseptic, be- 
sides anaesthetizing the inflamed skin sufficiently to admit of the 
strong alcoholic solution being used without producing pain. The 
iodoform solution is left in the ear with the patient's head inclined 
to the opposite shoulder for ten minutes, when it is allowed to drain 
slowly out, leaving a covering of iodoform powder on the surface of 
the drum-head and walls of the meatus. This treatment destroys any 
remaining fungi. The canal is then dried and dusted with a coating 
of aristol, and stoppered with absorbent cotton until the next treat- 



64 DEFORMITIES OF THE EXTERNAL AUDITORY CANAL. 

ment on the following or second day. Should there be a considerable 
exudation of serum, boric-acid powder may take the place of aristol 
or may be added to it. If the drum-head has been perforated or if 
the mastoid cells have been invaded, suitable treatment, such as will 
be detailed in the chapters on those subjects, must be adapted to such 
complications. 

Exostoses or bony growths from the osseous section of the ex- 
ternal meatus are so rare that we will not enter into their considera- 
tion here, except to remark that unless they occasion serious trouble 
they do not require attention; but if they become obstructive they 
must be removed. 

Imperforate External Meatus. 

At the Tenth International Medical Congress the author reported 
four cases of complete closure or absence of the auditory meatus, — 
two traumatic and two congenital. In the two congenital cases no 
external canal could be demonstrated. One of the traumatic cases 
Mas produced by a railroad accident that amputated the auricle, which 
was replaced and carelessly sewed over the canal to present a good 
appearance at the funeral; but the patient recovered. A few years 
afterward the author made a new canal, maintained its patency by 
means of a hard-rubber tube, and succeeded in restoring the useful- 
ness of the organ. The other traumatic case was a man 32 years of 
age. It was caused by a wagon-wheel severing the auricle irom the 
head when the patient was 3 years old. The same error was com- 
mitted in stitching the auricle over the mouth of the canal. When 
the patient came for treatment there was a discharge of pus from a 
very minute fistula in the roof of what should have been the canal. 
I opened the canal, cauterized the cicatricial tissues, and maintained 
the opening by means of a vulcanite tube. In the two congenital 
cases I operated on one, a girl 6 months old, but found no osseous 
canal; in the other, an infant of 14 months, no operation was ad- 
vised. Adhesions causing closure of the canal are very rare. 

Some of our authorities speak of imperforate external auditory 
canals as though they were of frequent occurrence; but among my rec- 
ords, embracing more than 21,000 cases of diseases of the ear, we 
found but 1 case of closure from exostosis, 3 cases of congenital ab- 
sence of the meatus, and 3 of traumatic closure. There were numer- 
ous cases of narrowing, and various irregularities of the canal, from 
causes that are not uncommon. 



foreign bodies in the external auditory canal. 65 

Foreign Bodies in the External Meatus. 

It is a common occurrence to find peas, beans, pebbles, and glass 
beads that children have introduced into their own or their com- 
panions' ears. We have found flies, bed-bugs, live moth-millers, etc., 
but flies are oftener found in suppurating ears. It is not uncommon 
to find oats and other foreign bodies that have remained in the ears 
for years without provoking symptoms that made their presence 
known. Sir William Bartlett Dalby found a piece of slate-pencil 
that had been in the ear for 30 years, and a stone that had been 
there for over 50 years. Xotwithstanding this, a foreign body is a 
menace to the integrity of the hearing organ so long as it remains in 
the canal. It may at any time set up an inflammation either by 
mechanical irritation or, if it be an organic substance, by swelling 
and by decomposition. 




Fig. 35. — Ear-forceps. 

These bodies are easily seen if the forehead-mirror, bright light, 
and a funnel are employed. But the funnel must not be allowed to 
crowd the body down farther into the canal. Insects, if alive, should 
either be immediately picked out with the delicate forceps (Fig. 35) 
or drowned by filling the ear at once with warm water. Beans, corn, 
peas, etc., absorb moisture and swell so as to completely fill the canal 
until their pressure becomes painful. They are easiest removed by 
passing the little sharp hook, contained in the author's middle-ear 
case, over the grain with the hook lying in an horizontal plane next 
the canal-roof; or, if there is greater space at any other point, we 
should choose it and carry the hook well over the berry, then turn the 
point toward the centre of the berry and press it firmly so as to imbed 
it in its substance. Careful traction will then extract it. Hard, 
inorganic bodies are not so easily extracted. Syringing is safest, with 
the head inclined toward the basin so that gravity will aid in their 



66 FOREIGN BODIES IN THE EXTERNAL AUDITORY CANAL. 

expulsion. Tliey may be wedged into the meatus so that the current 
of water cannot dislodge them. Then the little blunt lever, instead 
of the sharp hook, may be passed behind the body and drawn upon, 
care being had not to allow it to slip over or around the body, leaving 
the latter behind. When glass beads work into the middle ear, the 
operation for extraction is not so simple a matter. The author has 
the ornament of a "ruby" ring that could not be removed from the 
tympanic cavity until we had detached the auricle and chiseled away 
a section of the bony canal. The "ruby" is five-sixteenths of an inch 
(eight millimetres) in diameter and cut similarly to a diamond; so 
that instruments could gain no hold upon the facets. D. B. St. John 
Eoosa and Albert H. Buck report similar cases. Eoosa removed a 
shot from the middle ear, and Buck extracted a hard locust bean by 
means of the same operation. 

Extreme care should be exercised, in efforts to remove foreign 
bodies, not to injure either the canal or drum-head and ossicles. We 
have seen numerous instances in which unskillful practitioners had 
mutilated the canal-walls and drum-membranes, and even extracted 
the little bones before they discovered that there really had been no 
foreign body in the ear. Such practices are appalling. It is fre- 
quently necessary to assure anxious parents that they and their chil- 
dren are mistaken, when they bring their little ones to have foreign 
bodies extracted, for we often find that there is absolutely no evidence 
that any foreign body has been there. 






PLATE 1. 



PLATE I. 

Fig. 1.— Normal membrana tympani of the right side, showing the incudo-stapedial joint. 

Fig. 2.— Hypersemia of the right tympanic membrane. Slight injection of the vessels run- 
ning alongside of the hammer. Injection of the radiating vessels of the posterior segment, in a case 
of otitis media acuta. Duration. 9 days ; female patient ; age, 87 years. 

Fig. 8.— Injection of the radiating blood-vessels of the left tympanic membrane in a state of 
retrogression. A case of acute otitis media of ten days' standing ; female patient ; age, 45. 

Fig. 4.— Myringitis bullosa, showing formation of a blister the size of a hemp-seed, situ- 
ated behind the umbo ; second day of the disease ; male patient ; age, 19. 

Fig. 5. — Myringitis granulosa with extensive formation of sharply-defined wart-like eleva- 
tions or excrescences on the lower segment of the tympanic membrane. Numerous punctiform 
light-reflections appear on the granular surface. Duration, 6 months; age, 25. Completely cured 
after several applications of liquor ferri sesquichlorati. 

Fig. 6.— Myringitis granulosa chronica, the granulations covering nearly the entire tym- 
panic membrane. Duration unknown ; female ; age, 2(5. 

Fig. 7.— Catarrh of the middle ear, with secretion of an intensely-yellow color in the lower 
portion of the tympanum, and bulging of the lower segment of the drum-head. Duration, 2 weeks ; 
for four days there had been a marked injection of the vessels surrounding the handle of the hammer 
and those supplying the upper segment of the membrane. Acoumeter heard only on contact; 
conversational voice close to the ear. Age, 15. 

Fig. 8.— Secretive middle-ear catarrh, with great retraction of the tympanic membrane, 
which is of a yellowish-gray color. The posterior fold of the membrane is extremely prominent, 
and the lateral and middle folds of Shrapnell's membrane are well defined. Duration, 14 days ; 
age, 28. 

Fig. 9. — Chronic middle-ear catarrh. Retraction of the tympanic membrane, the hammer 
being invisible owing to the great prominence of the posterior fold, which describes a curve extend- 
ing from the short process above and in front and terminating below and posteriorly in the lower 
segment of the membrane. 

Fig. 10.— Chronic catarrh of the middle ear with cretaceous deposit in the drum-head, 
anterior to the hammer-handle. 

Fig. 11.— Two crescentic deposits of chalk embracing the handle of the malleus. Great im- 
pairment of hearing associated with continuous subjective noises in the ear. Duration more than 
6 months ; female ; age, 18. 

Fig. 12.— Crescentic chalk deposit enveloping the umbo, or the deep concavity correspond- 
ing to the inferior extremity of the malleus. 

Fig. 13.— Acute suppurative inflammation of the middle ear. Tympanic membrane of a red 
color and covered with a thin layer of exudation. A round perforation in the lower segment. 
Otorrhoea is said to have developed one hour after the painful symptoms began. Duration, 14 days ; 
age, 39. 

FrG. 14. — Acute suppurative inflammation of the middle ear, tubercular. Anterior half of 
the drum-head is deeply injected, the posterior segment has a pale-gray color. Behind the malleus 
are two small tubercular "excrescences, a capillary blood-vessel crossing them from above. Two 
minute punctiform perforations above the tubercles. Duration, 5 days ; age, 25. 

Fig. 15. — Acute suppurative inflammation of the middle ear. Drum-head is yellowish gray, 
the external layer of the membrane appearing quite loose. Processus brevis scarcely visible. 
Beneath the umbo is a minute perforation. Duration, 12 days ; age, 33. 

Fig. 16.— Chronic suppurative inflammation of the middle ear. Oval perforation in the an- 
terior, inferior quadrant of the drum-head ; round perforation in Shrapnell's membrane. The ex- 
ternal layer of the remaining portion of the membrane is quite loose and of a gray color. Duration 
of the discharge from the ear was 2 years ; age, 28. 

Fig. 17— Chronic suppurative inflammation of the middle ear ; round perforation in the 
superior segment of the drum-head. The mucous membrane of the tympanic cavity is of a dark- 
red color, and the drum-head of a light-gray color. The short process is visible. Age,*ll. 

Fig. 18. — Chronic suppurative inflammation of the middle ear. Large defect of the pos- 
terior half of the drum-head. The mucous membrane covering the promontory is dark red and 
shining; the remaining portion of the membrane is grayish red. The handle of the hammer is 
hardly visible. In the upper portion of the perforation the round head of the stapes can be seen. 
Duration, 1U years; age, 41. 

Fig. 19. — Chronic suppurative inflammation of the middle ear, with extensive destruction 
of the membrana tympani. Toward the periphery is the narrow, grayish-Avhite remnant of the 
membrane. The mucous membrane of the inner wall of the tympanum is deeply red and swollen. 
The handle of the mallet occupies its normal position, hanging free in the perforation. Disease 
continued from childhood ; age, 22. 

Fig. 20.— Chronic suppurative inflammation of the middle ear ; very large perforation of 
the drum-head ; 'remaining portion grayish yellow and thickened ; somewhat bulging on account 
of a dark-red polypoid growth in the region of the promontory. Short process is barely visible. 
Duration, 10 years' ; female ; age, 29. 

Fig. 21. — Dry perforation below the umbo, the size of a pin-head ; blood-vessels around the 
handle of the hammer are much injected. The drum-head is grayish red. In front and behind the 
malleus are crescentic, serrated deposits of chalk. Duration, since childhood ; age, 41. 

Fig. 22.— Cicatricial adhesion of the.drum-bead to the inner wall of the tympanum. The 
membrane is retracted behind the malleus and attached to the incudo-stapedial joint. The an- 
terior portion of the drum-head, also, is retracted and attached to the inner wall of the middle ear. 
The unusually prominent handle of the mallet becomes less prominent as it extends downward 
toward the promontory, which is covered by scar-tissue. Duration unknown ; age, 28. 

Fig. 23.— Defect of the drum-head, only a small portion remaining, which is connected with 
the retracted handle of the mallet. The inner tympanic wall is of a grayish color. In front of the 
opening leading to the Eustachian tube a membranous septum is stretched, with a minute per- 
foration. Duration. 15 years ; female ; ajre. 56. 

Fig. 24 —Destruction of Shrapnell's membrane ; large bonv defect of the outer wall of the 
attic, through which the disarticulated head of the hammer is visible. The incus is missing. The 
tympanic membrane is opaque and marked by a sharp, white border toward the defect. Duration, 
20 years ; female ; age, 30. 

Reproduced, by permission, from the "Atlas der Beleuchtun^sbilder des Trommel fells in gesunden iind in Kranken 
Znstande." Fourteen plates, 390 drawings, von Prof. A. Politzer. Wien bei Braumuller & Sohn. 



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CHAPTEE VII. 

DISEASES OF THE MIDDLE EAR. 

Injuries of the Dbeai-head. 

The drum-head is occasionally ruptured by blows (Fig. 36), ex- 
plosions, concussions from fire-arms, the pushing of pencils or straws 
into the ear. or by pulling the ears of children. Gorham Bacon says 
that during the laying of the foundations of the Brooklyn bridge 
many of the men working in the caisson suffered from rupture of the 
drum-head: but A. H. Smith, the medical officer in charge of the 




Fig. 36. — Rupture of the anterior-inferior segment of the drum-head 
caused by a box on the ear. (After Politzer.) 



men, belieyed that, in all those who suffered from an aural affection 
after working in the caisson, there already existed some obstruction 
to the entrance of air through the Eustachian tubes. The mere rupt- 
ure of the membrane is not usually of very serious import, for it will 
probably close in a few days without treatment: but concussions or 
wounds may penetrate sufficiently to affect seriously the middle or 
internal ear. If no inflammation follow such accidents, the perfora- 
tion itself requires no treatment further than to protect it from the 
air-currents by a light pledget of sterilized cotton. The consequent 
affections are treated in their proper classifications. 

(67) 



68 inflammation of the membrana tympani. 

Inflammation of the Drum-head. 

Synonym. — Myringitis. 

Pathology. — Myringitis is of frequent occurrence and generally 
begins with an injection of the malleal plexus of vessels. At first 
they can be distinctly seen like minute red threads extending down- 
ward along the hammer-handle, but as the hyperemia increases they 
appear to coalesce until there is an even diffusion of redness envelop- 
ing the handle and overspreading the membrana Shrapnelli (Fig. 12) 
like an intense blush. This condition may co-exist with a dermatitis 
of the superior integumentary wall of the external meatus. In these 
eases one cannot discern any line of demarkation between the lining 




Fig. 37. — Section through the tympanic membrane, malleus, and upper 
and outer tympanic wall of a decalcified preparation. Is, ligament, mall, 
sup.; le, ligament, mall, ext.; s, membrana Shrapnelli; o, Prussak's space; 
r, system of cavities between the body of the malleus and incus and the 
external tympanic wall; t, tendon of the muse. tens. tymp. (After 
Politzer. ) 

of the wall and the drum-membrane. I remember to have seen an 
abscess in the drum-head of a violinist, located in the region of Prus- 
sak's space (Fig. 37). The hook-knife (Fig. 70) was introduced from 
above and brought downward and outward, dividing the external wall, 
thus laying the little abscess-walls open to view. Occasionally haemor- 
rhagic effusions are seen, but the blisters described by Politzer we 
have rarely observed. When the inflammation extends over the whole 
area of the membrane it assumes a cherry-red color, shining at first, 
swollen and dusky after serous infiltration takes place (Plate I). 



EUSTACHIAN TUBAL CATARRH. 69 

Etiology. — The cause usually lies in wind or cold water reaching 
the drum-head, swimming, instillations of irritating substances into 
the ear, fungi, or acute cold in the head. t 

Symptomatology. — The hearing is not necessarily diminished for 
speech, but, on the other hand, there may be increased sensitiveness 
to noises. The pain is often severe and throbbing in character, ac- 
companied with a feeling of fullness and pressure and subjective 
noises. Pain may be referred to the side of the head and neck, as 
well as to the ear itself. 

Diagnosis. — In the early stage in the absence of pain this is not 
difficult, for the symptoms are not indicative of middle-ear inflam- 
mation except the appearance of the membrane. In mild cases the 
patient may not be aware of the presence of the trouble, although 
inspection reveals it, and the hearing is believed to be normal; but 
in acute middle-ear inflammation the Eustachian tube is usually in- 
volved, a rapid serous exudation takes place, and swelling of the mem- 
brane, with marked impairment of hearing. All the symptoms are 
characteristic of a more profound disturbance. After the inflamma- 
tion extends from the drum-head to the middle-ear the differential 
diagnosis is out of the question and immaterial. 

Prognosis. — This is favorable, the disease being generally limited 
to a few days or a week. 

Treatment. — If the pain is not severe the symptoms subside on 
warming pure vaselin and letting it run down upon the drum-mem- 
brane. Then the ear is closed with cotton to retain it for twenty- 
four hours. In severe pain an 8-per-cent. solution of cocaine or 
eucaine, quite warm, gives relief used in the same manner. Xo other 
treatment is necessary except for complications or after-effects of the 
disease. 

Eustachian Tubal Catarrh, or Salpingitis. 

Pathology. — In Eustachian salpingitis the mucous membrane 
lining the tube may be simply hyperasmic or highly inflamed. Since 
it is lined with a continuation of the same mucous lining as that of 
the naso-pharynx, on the one hand, and of the tympanic cavity, on 
the other (Fig. 38), any inflammatory action in one is likely to spread 
along the membrane to another part, just as an erysipelatous inflam- 
mation of the skin travels along the integument from one part of the 
body to another. In a transitory inflammation of the tube, mild in 
character, the mucous membrane alone may be affected, with only 



70 



EUSTACHIAN TUBAL CATARRH. 



slight swelling and diminishing of its calibre; but in a severer grade 
the submucous layer becomes involved, transudation, of the fluid ele- 
ments of the blood takes place, and great swelling and stenosis or com- 
plete closure of the tube occur. As a result of the latter condition, 
new connective-tissue formation may make the narrowing or im- 
perviousness of the tube permanent, Both the inflammation and the 
constriction are mostly confined to the cartilaginous part of the tube, 




g h i ct 

Fig. 38.— Eustachian tube and tympanic cavity, a, membrana tym- 
pani; b, head of the malleus; c, lower end of the handle of the malleus; 
d, body of the incus; e, short process of the incus; f, tensor tympani; 
g, orifice of the Eustachian tube; h, isthmus of the tube; i, tympanic 
mouth of the tube. (After Politzer.) 



and the connective-tissue strictures to the middle of this portion. 
Granulations sometimes result from the inflammation. 

Etiology. — Tubal catarrh is rarely an idiopathic disease, but re- 
sults either from an attack of acute coryza, or pharyngitis, or from a 
middle-ear catarrh. Cold winds blowing on the side of the neck, a 



TREATMENT OF EUSTACHIAN TUBAL CATARRH. 71 

blow, or irritating fluids in the naso-pharynx may act as causes. The 
presence of hypertrophied oral or pharyngeal tonsils, or of adenoid 
vegetations in the vault of the pharynx, which are the seat of fre- 
quently-recurring attacks of inflammation, predisposes to the disease. 
Moreover, they form a nidus for pathogenic bacteria. 

Symptomatology. — In light attacks there are only slight deafness 
and subjective noises, which increase with the severity of the inflam- 
mation. When the tube becomes greatly swollen there may be vertigo, 
and pain referred to the side of the neck, back of the ramus of the 
lower jaw. Pressure toward the course of the tube reveals tenderness. 
Auscultation gives a high-pitched, squeaking noise during politzeriza- 
tion, and, if mucus is present, a rale also in a swollen condition of 
the tube. These are not necessarily present in the constriction due 
to connective-tissue growth. In the latter the noise may be wanting. 
It is difficult or impossible to inflate the ear, or it will require high 
pressure to do so. The drum-head is sunken on account of the rapid 
absorption of air in the tympanic cavity and loss of the normal ven- 
tilation by the tube. The lower extremity of the mallet may lie close 
to the inner wall of the cavity, giving the hammer-handle a fore- 
shortened appearance, and causing the short process to project out- 
ward prominently toward the examiner's eye. The membrane about 
this process looks stretched and drawn into folds. 

Diagnosis. — This is not difficult and the principal points have 
been indicated in what has already been said. With no middle-ear 
involvement, the most striking result is obtained from inflation. The 
hearing is immediately restored and the differential diagnosis is con- 
firmed. 

Prognosis. — The attack of acute catarrh of the tube is readily 
subdued, and proper treatment will soon restore the parts to a normal 
condition. 

Treatment. — This must be directed to the condition of the tube 
itself, to the causes that induce the attacks, and to the predisposing 
causes. The most immediate relief is afforded the patient if we can 
at once inflate the middle ear. This restores the normal hearing, re- 
lieves the tension of the drum-membrane, reduces the engorgement 
of the blood-vessels by relieving the partial vacuum; removes the 
cause of dizziness, the impaction of the stirrup; and lifts the patient 
out of his mental gloom, — a condition characteristic of this disease. 
The catheter should be avoided, since its introduction into the orifice 
of the inflamed tube serves only to increase the irritation. Politzeriza- 



72 TREATMENT OF EUSTACHIAN TUBAL CATARRH. 

tion is, by far, preferable, at first with air alone, to gently and gradu- 
ally fill the tympanic cavity and restore the drum-head to its normal 
position. Too sudden inflation in this state may cause distress, ver- 
tigo, and nausea by the disturbance of the intralabyrinthal fluid. 
The tube being opened, it is my practice to inject with the improved 
inflator (Fig. 26) either pure lavolin — a purified non-irritating fluid 
vaselin — or a weak solution of camphor-menthol in lavolin, 3 per cent. 
The former is bland and emollient, as well as protective to the in- 
flamed membrane. The latter relieves the pain, constricts the capil- 
lary blood-vessels, reduces the swelling and stenosis, and acts as an 
antiseptic and protective. If the tube does not readily yield to the 
inflation, 6 or 10 drops of sulphuric ether may be placed on the 
sponges of the inflator, and, with sufficient pressure from the com- 
pressed-air reservoir and while the patient swallows, this will, in most 
cases, reach the middle ear. There is not sutficient ether to produce 
irritation, but it is so volatile that it will penetrate where air alone 
fails to go. 

My experience differs somewhat from that of other observers con- 
cerning tubal affections. We have rarely met cases of constriction 
that we were not able to overcome without the use of the bougie. 
This may be attributed, perhaps, to the greater air-pressure employed 
in my work. Moreover, it is rarely found necessary to introduce the 
catheter, — for the same reason, no doubt. Hand-bags are little used 
in my private practice or in my three hospital and college clinics, but, 
instead, we make use of air in reservoirs compressed by hydraulic com- 
pound pumps, Westinghouse air-pumps, or some other device sup- 
plying at least three or four times the amount of force obtainable from 
the rubber air-bags. But the amount of pressure is regulated by valves 
and air-meters so as to place it under the control of the operator and 
render it safe. 

Bougies have their disadvantages. They may abrade or lacerate 
the membrane of the tube and penetrate its weakened walls, or they 
may be carried onward into the tympanic cavity and dislocate the 
ossicles or perforate the membrana tympani. Air and emollient or 
stimulating medicaments are devoid of these dangers. Generally but 
a few treatments are required to open the tube and maintain its 
patency. I remember but two cases in which it required as long as 
three weeks of treatment without the bougie to effect this result. 
One was in a chronic catarrhal condition with connective-tissue strict- 
ure, but the result was satisfactory. The other required the bougie. 






ACUTE INFLAMMATION OF THE MIDDLE EAR. 73 

A. B. Duel reports excellent results from electrolysis for stenosis (The 
Laryngoscope, February. 1898). The second indication for treatment 
is the reduction of the naso-pharyngeal or tympanic catarrh that may 
have given rise to the tubal trouble. But, since these conditions and 
the predisposing causes are treated of in their proper sections, we will 
not repeat here. 

Acute Inflammation of the Middle Eae. 

Synonyms. — Otitis media acuta: acute tympanitis. 

Pathology. — Otitis media acuta presents at first a glow of red- 
ness of the lining mucous membrane of the middle ear, due to the 
beginning hyperemia. This is perceptible through the translucent 
drum-head, and is followed rapidly by an effusion of serum and mucus 
into the tympanic cavity. These stages of inflammation follow each 
other in quick succession, and the disease itself is of short duration. 
The mucous membrane becomes tumefied and the epithelium becomes 
opaque and exfoliated. In a certain form of acute inflammation which 
is especially characteristic of the epidemic influenza, or, as it is gen- 
erally known, the grip, there is so sudden an exudation as to cause 
rupture of the blood-vessels, and within twelve or twenty-four hours 
of the onset there is a copious, bloody, serous effusion and rupture of 
the membrana tympani. I have observed an influx of this type of 
the disease within a few days of the breaking out of the epidemic in- 
fluenza in Chicago. 

Etiology. — This affection most often results from a cold in the 
head, and may be caused by an inflammation of any portion of the 
upper respiratory tract and by the eruptive fevers. Cold winds blow- 
ing in the ear. getting wet. bathing, influenza, cauterizing the nose 
and throat, pouring or sniffing cold fluids into the nose, and the en- 
trance of soap and water into the auditory meatus are prolific causes. 
It is more common to childhood than adult life. F. C. Hotz believes 
that malarial poison is sometimes a cause. 

Symptomatology. — Sensations of itching in the ear sometimes 
call the patient's attention to it before the actual pain begins, but 
the pains in other instances come on suddenly and without warning, 
and rapidly increase in intensity until they become unbearable. Espe- 
cially is this the case in children, who are thrown into a fever, de- 
lirium, and even convulsions, so exquisite is the suffering. The pain 
is increased by sneezing, swallowing, and coughing, and it may radiate 
to the side of the head and teeth, or there is a sensation of numbness 



74 



ACUTE INFLAMMATION OF THE MIDDLE EAR. 



in the corresponding side of the head. Autophony, or a peculiar 
sound of the patient's voice as perceived by himself, adds to his dis- 
comfort. If great pressure is exerted by an abundance of exudation, 
giddiness is experienced. Undoubtedly the labyrinth often partici- 
pates in the disturbance to the extent of becoming hyperamiic, in 
which case subjective sounds become intense and even rhythmic, vary- 
ing synchronously with the heart's pulsations. It is not unusual to 
meet with a mild type of this disease in which all the symptoms are 
diminished in intensity and some are absent. Before the exudation 
occurs the hearing may show no impairment, but afterward it de- 
creases proportionately to the amount of tumefaction and secretion. 
Bone-conduction is normal. 

Inspection reveals, in the beginning of the attack, a drum-head 
presenting the appearance described under the caption of "Myringitis* 7 




Fig. 39. — Radiate vascular injection of the drum- head. (After Politzer.) 



(Fig. 39), Plate I. The malleal plexus of vessels is injected with 
blood; their tracery along the upper region of the hammer-handle 
is distinctly made out; a red areola shows about the processus brevis, 
and later a glow of redness covers the membrana naccida. As the 
inflammation progresses the red appearance extends to every part of 
the membrane until it looks like a cherry in the ear. Later, as the 
serous infiltration increases, the outlines of the handle become dimmed 
and disappear; the lustre of the membrane is lost, and in its place a 
dull, swollen surface presents. When the tympanic cavity becomes 
filled with secretions, inequalities of the surface of the membrane are 
visible, and a bulging in some part may indicate the pressure of fluid 
from within. Indeed, the whole membrane may become bulged out- 
ward, and the radiate traceries of the injected vessels show like the 
spokes of a wheel (Fig. 40). 

As the inflammation subsides the redness of the drum-head fades 






TREATMENT OF ACUTE IXFLAMWATIOX OF THE MIDDLE EAR. , 5 

away, the pain ceases, the hearing improves, the noises diminish, and 
a general sense of relief takes the place of a stormy experience. The 
membrana tympani assumes a lustreless, ashy-gray color, and its 
opacity remains for a considerable time, and may become permanent. 

Diagnosis. — There is little likelihood of confounding this disease 
with any other save myringitis alone. The latter forms a factor in 
the present case and can, without much confusion, be separated from 
it. In the inflammation involving the whole of the cavity all the 
symptoms of inflammation of the drum-head alone are augmented, 
while others are ingrafted upon it. The great impairment of hear- 
ing after effusion, the general symptoms, and their duration are de- 
cisive. Children work at the affected ear, press it against warm ob- 
jects, or incline the head to the diseased side. 

Prognosis. — The tendency is to resolution in healthy patients 




Fig. 40. — Eadiate. vascular appearance in acute inrlanmiation of 
the middle ear. (After Politzer.) 

under favoring circumstances. In the opposite condition the tend- 
ency is either to suppuration and perforation of the drum-head or 
to a chronic dry catarrhal state. 

Treatment. — In the first stage, or before the serous effusion has 
taken place or the pain has become severe, gentle inflation and filling 
the ear-canal with warmed pure, or carbolated, vaselin will suffice to 
give relief. TThen the pain has become intense, inflation must be 
made under very low pressure, as the movements of the drum-head, 
like those of an inflamed joint, are exquisitely painful. The patient 
in this stage should be put to bed to keep the temperature equable. 
a warm 8-per-cent. solution of cocaine or eucaine may be instilled into 
the ear, and, if deemed necessary, 1 / 8 grain of morphia can be given 
in combination with V 400 grain of atropia for an adult. If for any 
reason the morphia and atropia should not be prescribed, bromidia 
may be substituted in teaspoonful doses, in water, every half-hour 



76 TREATMENT OF ACUTE INFLAMMATION OF THE MIDDLE EAR. 

until relief is obtained. Then it must be discontinued. The bowels 
and general health should receive proper attention. We have often 
found that leeches gave speedy relief. Two Spanish leeches may be 
applied in front of the tragus and two behind the auricle for adults. 
The external canal is stoppered with cotton so that the leeches can- 
not enter it. The skin is pricked until a drop of blood appears; then 
the leech in a two-drachm vial, with its mouth at the opening of the 
bottle, is placed so that its mouth covers the drop of blood. The vial 
is held in position until the leech takes secure hold. Then the bot- 
tle is removed and the leech allowed to fill and drop off. This man- 
ner of applying leeches is given because few seem to be conversant 
with the subject, and this method removes the common objection to 
handling such repulsive animals. Especial care should be exercised 
to abstract the blood in middle-ear inflammation as much as possible 
from the region of the tragus, on account of the intimate relation of 
the blood-vessels of this region and the anterior wall of the meatus 
with the vessels of the tympanic cavity. If enough blood has not 
been abstracted after the leeches fill and fall off, more can be drawn 
by applying napkins wrung out of warm water. If there should be 
any difficulty in stopping the bleeding of the leech-bites, pressure 
applied to them will succeed. The artificial leech is also an excellent 
device, but occasions more discomfort. 

The common practice indulged in by the laity of pouring oils, 
onion-juice, etc., into the ear is a vicious one, since these become 
rancid and irritating and predispose to a subsequent inflammation. 
Poultices are also mischievous and favor suppuration and perfora- 
tion of the drum-membrane. The author has seen the following sim- 
ple device, always convenient, give grateful relief: A piece of clean 
cotton is placed lightly in the mouth of the canal. A pipe is partly 
filled with tobacco and lighted. Then a piece of thin cloth is placed 
over the mouth of the pipe-bowl and gently blown through, while 
the lip-piece of the pipe-stem rests against the cotton pledget. This 
filters the warm smoke through the cotton into the canal, and a grate- 
ful sedative effect is soon obtained. I do not remember to have seen 
this remedy mentioned, but its efficacy in the absence of other reme- 
dies has been demonstrated. 

Fever calls for antipyrin or its equivalent in some febrifuge that 
is less of a cardiac depressant. Phenacetin and acetanilid act well. 
Quinine, the enemy of the ear, must not be used. It aggravates the 
existing hyperemia and conduces to permanent deafness. Alcoholic 



TREATMENT OF ACUTE INFLAMMATION OF THE MIDDLE EAR. , i 

drinks and smoking are prohibited, and any inflammatory condition 
of the respiratory tract must he vigorously combated. 

If the pain and bulging of the drum-head continue, notwith- 
standing all efforts to counteract the disease, and rupture of the mem- 
brane is threatened, it should be incised with the paracentesis-knife 
(Fig. 57, Xo. 2), in the postero-inl'erior quadrant, so as to afford the 
most perfect drainage. A warm, 8-per-cent. solution of cocaine or 
eucaine should be left in the ear for twenty minutes before the para- 
centesis, and, if the pain does not soon cease after perforating, more 
cocaine should be instilled, as hot as can be comfortably borne, so as 
to percolate through the perforation and reach the mucous membrane 
within. This will give relief. The incision should be a long one, 
cutting through the entire area of the postero-inferior quadrant ver- 
tically. The longer it is, the more it relieves the tension of the nerves 
of the membrane and the freer the drainage. The paracentesis-knife 
must be absolutely sharp and dipped in alcohol before using. The 
perforation generally heals in a few days if no pus has formed. If 
we find suppuration has taken place, then we have a condition which 
is considered in the following chapter. 

After the pain is relieved, which should be the object of our first 
efforts, the ear may be inflated with as low pressure as will accom- 
plish it. The air-pressure in the tympanic cavity promotes absorption 
of any fluid contents and will likely improve the hearing. This treat- 
ment is administered daily for a few days. As improvement progresses 
the treatments can be given at greater intervals until the normal con- 
dition is established. 

Diet, exercise, and clothing should be regulated on general hy- 
gienic principles. 



CHAPTER VIII. 

DISEASES OF THE MIDDLE EAE, CONTINUED. 

Acute Suppurative Inflammation of the Middle Ear. 

Synonyms. — Otitis media acuta suppurativa; acute suppurative 
tympanitis. 

Pathology. — The tissue changes already set forth in the descrip- 
tion of acute inflammation of the middle ear take place in the affec- 
tion now under consideration previously to pus formation. In the 
suppurative form the inflammatory action is more intense; the tis- 
sues break down; the drum-head bulges with the pressure of the 




Fig. 41. — Convexity of the drum-head due to pressure from 
within. (After Politzer.) 



accumulated fluids (Fig. 41), becomes softened, and, yielding to the 
consequent pressure, ruptures. The whole tympanic cavity becomes 
involved, and the purulent discharge may find its way into the mas- 
toid antrum and cells. This disease is practically a sequel of the one 
described in the foregoing chapter. 

Etiology. — The causes of acute inflammation of the tympanum 
and those that give rise to suppuration are identical, and to avoid 
unnecessary repetition the reader is referred to the preceding chapter. 
But, in the case of suppuration, there is probably an invasion of the 
middle ear by micro-organisms through the Eustachian tube. Bezold 
found the diplococcus pneumoniae in suppuration of the middle ear 

(78) 



ACUTE SUPPURATIVE INFLAMMATION OF THE MIDDLE EAR. 7b) 

in pneumonia. Streptococci or pnemnoeocci are usually found in 
acute suppuration, followed by the staphylococci pyogenes. 

Symptomatology. — The symptoms here are a repetition of those 
already described in treating of acute inflammation up to the point 
of pus production, but in a certain proportion of cases the acute in- 
flammation runs its course without the train of distressing symptoms 
there described. It often happens, especially in children, that the 
first intimation the parents have of any ailment is the appearance of 
a discharge from the little one's ear. On the other hand, some chil- 
dren are so violently affected as to suggest meningeal or brain com- 
plication. In diseases that simulate intracranial affections the phy- 
sician should never fail to examine the ears. 

Diagnosis. — Before perforation takes place it may be impossible 
to differentiate between a simple acute inflammation with serous ex- 
udation into the tympanic cavity and a suppurative inflammation. 
As soon as rupture of the membrane occurs and the muco-purulent 
fluid is discharged into the meatus the diagnosis is cleared up. The 
appearance of the perforation (Plate I), which can generally be seen 
after removing the discharge, and the presence of the latter not being 
due to an inflammation of the meatus, together with the whistling- 
sound resulting from forcing the air through the perforation during 
politzerization, present the factors of a positive diagnosis. 

Prognosis. — If the habits of body are bad, — tubercular, syph- 
ilitic, etc., — or if the suppuration result from diphtheria or scarlet 
fever, the prognosis is unfavorable; otherwise, when all the symp- 
toms are ameliorated soon after the discharge appears, the outlook is 
favorable. There is reason for apprehension if the severity of the 
symptoms continue unabated after a free exit for the secretions has 
been provided for, either by nature or the surgeon. The author has 
often observed that when the inflamed parts showed pulsation and 
were very sensitive to the gentlest touch of the cotton-fluff, the sup- 
puration was difficult to cure. The pulsation, which is synchronous 
with the heart-beats, can be seen distinctly if bright light is caused 
to be reflected from a moist spot on the drum-head. The pulse can 
easily be counted in this manner. Bulging of either the posterior 
or superior wall of the meatus, or symptoms referable to the mastoid 
process, burrowing of pus, periostitis, or osteitis are indicative of 
serious complications. 

Treatment. — In the preceding chapter, in treating of acute in- 
flammation of the middle ear, are given in detail the methods that 



80 TREATMENT OF ACUTE SUPPURATION OF THE MIDDLE EAR. 

should be adopted in acute inflammation up to the time of suppura- 
tion and rupture or paracentesis of the membrana tympani, to which 
the reader is referred. Taking up the subject then, at the point where 
rupture has occurred by the efforts of nature to cast off noxious ma- 
terial and relieve pressure, the first observation to be made is relative 
to the capacity of the perforation to meet the necessity for free drain- 
age. If the fluids are copious and the opening is too minute to admit 
of sufficient freedom of exit to the discharge, especially if the pain 
be continuous, the perforation should be enlarged vertically, as has 
been already described in the treatment of otitis media acuta, The 
tympanum must also be rendered freely accessible to the surgeon for 
the purposes of cleansing, disinfecting, and medicating the inflamed 
membrane within. 

Assuming now a free perforation, the external canal is dried out 
very gently with a fluffy cotton-twist projecting a quarter of an inch 
beyond the end of a small soft-silver cotton-carrier (Fig. 9). The 
cotton is rolled over the point of the carrier firmly enough to prevent 
it from penetrating the cotton and wounding the tissues, but beyond 
the twisted portion the cotton should be left in a downy tuft to absorb 
rapidly the fluids and to avoid any abrasion of the membrane. The 
cotton can be carried down into the fundus of the canal and brought 
in contact with the drum-head repeatedly until all the secretions are 
absorbed and extracted. As the last of these are dried up, the fluid 
from within the cavity may be seen oozing out, a drop at a time, or 
rolling down from a nipple-like perforation (Fig. 42). If one is not 
expert in the manipulation of these instruments, it is better to cleanse 
the canal by syringing it with a quart of water as warm as can be 
comfortably borne, the water having been sterilized by boiling for ten 
minutes. 

After freeing the meatus of all discharges the ear is carefully 
inflated with as low pressure as will propel a column of air outward 
through the perforation. The discharges are by this means projected 
through the perforation into the canal with a whistling or bubbling 
sound. If too great force is exerted, unnecessary pain is caused. Any 
fluids ejected into the meatus are then removed; the canal is dried, 
and insufflated with aristol from the small powder-blower (Fig. 34). 
This remedy is preferable to boric acid in that it possesses a feeble 
anaesthetic property. It is an excellent cicatrizant, and, being an 
impalpable powder, it can be dusted through a narrow perforation. 
Or we may employ nosophen which, having no odor or irritating quali- 



TREATMENT OF ACUTE SUPPURATION OF THE MIDDLE EAR. 81 

ties, with decided antiseptic and healing properties, possesses decided 
merits. It is a very light, impalpable powder, that is easily thrown 
in the form of a dust over the surface treated. Its color is yellowish- 
gray, and it contains nearly 62 per cent, of iodine in combination. 
It is not decomposed by heat up to 220° C, and it is not soluble in 
water. Xosophen does not act as iodoform does by liberating free 
iodine as it decomposes in contact with the living tissues; but con- 
tact with the alkaline fluids of the body converts the insoluble noso- 
phen into the soluble antinosine, and no free iodine is liberated by 
either to produce toxic effects. But, through this gradual transforma- 
tion of nosophen into antinosine, we get a continuous effect of the 
remedy. A small pledget of absorbent cotton is then introduced 
lightly into the mouth of the meatus and allowed to remain until a 




Fig. 42. — Nipple-shaped bulging of the posterior portion of the drum-head, 
on the summit of which is the perforation. (After Politzer.) 



further discharge appears. Patients are instructed to let their ears 
entirely alone in case they remain dry after treatment, but if the 
cotton becomes moist with the discharge they are to syringe the ear 
(Fig. 33), as previously described, and instill a warm, saturated solu- 
tion of boric acid in water or rose-water, allow it to remain ten min- 
utes, then let it escape, and close the ear lightly again with clean 
cotton. 

The cotton stopper protects the sensitive drum from cold winds 
or drafts and absorbs moisture. This constitutes an ideal dry dressing, 
and in suppuration of the ear, as of other organs, the drier the treat- 
ment, the better the results. The ear already presents the most favor- 
able condition for the development and propagation of bacteria, — 
warmth and moisture. This condition we must combat; so that, 
whatever our treatment may consist in, the aim should be to leave 



bZ TREATMENT OE ACUTE SUPPURATION OF THE MIDDLE EAR. 

the parts as dry as possible. For this reason "boric acid is an excellent 
dressing, especially when all acute symptoms have subsided. How- 
ever, during the acute stage boric acid may cause pain for several 
hours after its application. We have met with quite a number of 
such instances in which it became necessary to discontinue the use 
of this powder. We have suspected that certain individuals possess 
an idiosyncrasy against it, but, if it produce no discomfort, excellent 
results may be expected. It absorbs moisture and dries the tissues. 
If fluids come in contact with it a saturated solution of boric acid is 
formed, which may percolate through the perforation into the middle 
ear and there exercise its feebly germicidal power. No powder, how- 
ever, should be firmly packed into the ear, for it would prevent the 
■escape of discharges and cause them to seek an outlet elsewhere: 
through the Eustachian tube if it were fortunately pervious, or 
through the mastoid antrum and cells, or even by way of the internal 
meatus or the tympanic roof to the cranial cavity. Moreover, it 
should never be forgotten how intimately the middle ear and mastoid 
spaces are related to the contents of the cranial cavity by the con- 
necting blood-vessels, lymphatics, and by occasional defects in the 
superior surface of the temporal bone. These conditions emphasize 
the necessity of always keeping the passage-way for the flow outward 
unobstructed. 

In case the drum-membrane and the canal remain very sensitive 
and pain continues unabated in the ear, a 12-per-cent. solution of 
carbolic acid in glycerin generally gives relief. The acid anaesthetizes 
and disinfects without corroding the tissues when combined in this 
proportion with glycerin, and the latter unloads the blood-vessels of 
their superabundant serum. The turgescence of the vessels is dimin- 
ished and the pain relieved. General treatment is to be resorted to 
when the conditions demand it. The body should be protected from 
sudden atmospheric changes by wearing wool next the skin. Further 
elucidation of this subject will be found under the heading of "Treat- 
ment" of coryza. 

Since the disease under consideration is largely the result of 
acute catarrh of the nose and throat, coincident treatment should 
always be addressed to the naso-pharyngeal affection, and our efforts 
must be directed toward removing any permanent causes of recurring 
attacks, such as hypertrophies in the nasal chambers, adenoid growths 
in the pharynx, and enlarged tonsils. (See chapters on these subjects.) 



CHRONIC CATARRH OF THE MIDDLE EAR. 



S3 



Chroxic Xox-slppurative Inflammation of the Middle Ear. 

Under this name are classed hypertrophic middle-ear catarrh 
and adhesive middle-ear catarrh, — sclerosis (see Chapter IX). 

HYPERTROPHIC, OR SECRETIVE, CATARRH OF THE MIDDLE EAR. 

Synonym. — Hypertrophic tympanitis. 

Pathology. — Hypertrophic, or secretive, catarrh of the middle 




Fig. 43. — Fluid effusion in the tympanic cavity, marked by a 
bright line. (After Politzer.) 



ear generally occurs in association with a similar condition of the nose 
and naso-pharynx. There is an liyperaemic condition of the mucous 
membrane lining the tympanic cavity, with hypersecretion of a serous 
or mucous character. The exudation may be visible (Figs. 43 and 




Fig. 44. — Circumscribed bulging of the drum-head, due to pressure 
of fluid in the middle ear. (After Politzer.) 



44 and Plate I) if the drum-head has not lost its translucency, more 
especially when air has been forced through the Eustachian tube into 
the fluid, thereby causing bubbles or a frothy appearance. In this 
disease the tube generally participates to the extent of losing its 



84 HYPERTROPHIC CATARRH OF THE MIDDLE EAR. 

patency; so that the normal supply of air in the tympanic cavity is 
cut off. The result is that the air in the middle ear is absorbed; so 
that the resistance of the drum-head to the outer atmospheric pressure 
of nearly fifteen pounds to the square inch is lost, and the membrane 
is forced inward toward the inner tympanic wall. The effect of this 
encroachment upon the tympanic space is easily visible in the in- 
creased concavity of the membrane, the foreshortening of the hammer- 
handle, the emphasizing of the posterior fold, and the changed loca- 
tion of the reflection of light. 

The drum-head yields to the atmospheric pressure from without 
when the counteracting air-pressure from within is lost, and lies, pos- 
sibly, in contact with the inner wall, especially the posterior half. In 
this case it may so embrace the long process of the anvil and the poste- 
rior cms of the stirrup as to show their projecting outlines and those 




Fig. 45. — Great concavity of the drum-head and foreshortening of 
the hammer-handle. (After Politzer.) 



of the promontory and round window. The mallet-handle may at 
first seem to be invisible until one looks from below upward as much as 
possible, when it is seen occupying an almost horizontal position (Fig. 
45 and Plate I), running directly inward until its lower extremity 
lies in contact with the inner wall of the cavity (Fig. 48). The short 
process is thrown outward by this position toward the examiner's eye 
like a little yellow knuckle covered with membrane that is stretched 
into tense folds above. If the drum-head is still lustrous the triangle 
of light has been moved from its normal position, or there is a cir- 
cular reflection of light from the most depressed section, or there may 
be several dots of light, owing to the irregular surface produced by 
the varying degrees of depression in different parts of the membrane. 
In an advanced stage these irregularities of retraction are due to an 
atrophied condition of one or more parts of the membrane, and, un- 



HYPERTROPHIC CATARRH OF THE MIDDLE EAR. bo 

less a careful inspection is made, these atrophies may be easily mis- 
taken for cicatrices. The latter, however, are more clearly defined 
by the distinct line forming a border to a previous perforation and 
now separating the cicatricial tissue from the opaque, thickened sur- 
rounding membrane. The atrophic area blends gradually in more 
indefinite outlines with the adjoining hypertrophic tissue. 

The manipulation of the massage otoscope (Fig. 8) shows these 
atrophic and cicatricial sections with unmistakable clearness. When 
the air is rarefied in the canal, these spots bulge outward like balloons, 
as if they might burst. Indeed, they probably could be easily ruptured 
if much force were exerted. They show exaggerated movements when 
the remainder of the membrane and the mallet are completely quies- 
cent. But, when the drum-head is depressed against the inner tym- 
panic wall and has become adherent to it by organic adhesions, these 
adhesions prevent the depressed area from responding to the pneu- 
matic otoscope. 

In the advanced stage of this disease the drum-head may become 
very greatly thickened and of a milky opacity, and hypersecretion and 
impaction of cerumen are frequently found. 

Etiology. — Acute colds in the head, influenza, the eruptive fevers, 
chronic naso-pharyngeal catarrh, and syphilis act as the exciting 
causes of this affection. Impermeability of the Eustachian tube, with 
consequent rarefaction of the air in the middle ear, causes an exuda- 
tion of serous fluid, retraction of the drum-head, etc., which may only 
prove to be transitory if the cause of the tubal stenosis is speedily 
removed, or, if it is not, permanent tissue changes may occur, result- 
ing in the more serious conditions described. George A. Leland makes 
the point that ear disease results from frequent and forceful efforts 
to cle,ar the nose. The air is blown into the middle ears with suffi- 
cient pressure to stretch the drum-heads and cause ultimate relaxa- 
tion. 

Symptomatology. — This is not a painful affection, although in 
the early stages slight twinges or darting and shooting transitory pains 
may occur. Sensations of fullness in the ear, pressure, and as if some- 
thing were moving in the ear are complained of. The last symptom 
is produced by movements of the fluid contents of the tympanic cav- 
ity, owing to the varying positions of the head, and to the entrance 
of air into the fluid through the tube. The last cause also gives rise 
to bubbling, snapping, and crackling sounds. These rales result from 
the separating of the walls of the Eustachian tube also, when it is 



86 TREATMENT OF HYPERTROPHIC CATARRH OF THE MIDDLE EAR. 

involved, as air passes through. The viscous mucous secretion ag- 
glutinates the walls together, and as they separate the clinging mu- 
cus first sticks, then stretches into filaments, and finally the breaking 
of these occasions the crackling noises. The movements of the jaw 
aggravate these symptoms. Sensations of numbness in the corre- 
sponding side of the head, confusion of ideas and speech, irritability 
of temper, and autophony — or a disagreeable hollow sound of one's 
own voice, as if talking into an empty barrel — are characteristic of 
this disease. 

The swelling of the tissues and increased tension of the drum- 
head and ossicles may produce labyrinthal pressure with a sense of 
light-headedness, giddiness, and subjective noises, although the latter 
constitute one of the principal symptoms of sclerosis. The hearing 
varies greatly with the weather conditions. Low barometer and ther- 
mometer, with great humidity of the atmosphere, increase the impair- 
ment of hearing, the sensations of stuffiness and fullness, and tinnitus 
aurium. Sudden changes to these atmospheric conditions from a 
warm, dry air are certain to aggravate the aural symptoms. Patients 
can predict approaching weather changes by the phenomena men- 
tioned. Alcoholic stimulants and colds in the head also increase 
these distressing symptoms. 

Diagnosis. — It is not difficult to determine the presence of the 
secretive form of catarrh. If the drum-head is yet transparent the 
line in the membrane indicating the surface of the liquid (Fig. -±3) 
can be made out unless it extends above into the attic, or the pro- 
pelling of air into it can be heard to produce bubbling sounds, and 
in the early stages the hearing may not be greatly impaired or it is 
much improved by politzerization. The patient is generally young, 
bone-conduction for the watch and tuning-fork is good, and the dis- 
ease is far more amenable to treatment than is sclerosis. 

Prognosis. — This is favorable if we can exclude heredity, bad 
sanitary influences, and general ill health, and if the attack is not of 
long duration. Especially is this so if inflation of the ear and removal 
of any contained fluid result in decided improvement in the symptoms 
and if the bone-conduction is good. But examination of the nose and 
throat will throw important light on this subject. If there are no 
hypertrophies and exostoses, but a simple catarrh of recent origin, a 
cure is rapidly effected. 

Treatment. — Attention must first be directed to the passages that 
lead to the middle ear. If there is a catarrhal condition of the nose 



TREATMENT OF HYPERTROPHIC CATARRH OF THE MIDDLE EAR. 87 

and throat that may have given rise to the middle-ear disease, it should 
receive proper treatment at the same time with the Eustachian tube 
and tympanum. Permanent cure of the ear affection cannot be 
effected so long as the exciting cause of such attacks remains in the 
naso-pharyngeal tract. The Eustachian tube, if diseased, should be 
the subject of proper measures to render it permanently patulous and 
healthy. The air-douche by the Politzer air-bag or the compressed- 
air apparatus is sufficient in many recent cases to cause absorption of 
secretions in the middle ear and the reduction of hyperemia and swell- 
ing of the mucous membrane. By this means the natural ventilation 
of the tube and tympanic cavity is effected and the drum-head is 
restored to its normal position and tension. This inflation should be 
carried out daily until the improvement obtained at each visit remains 
permanent until the next: then the time is lengthened to two, three, 
or four days or more, or a week or two between the treatments, accord- 
ing to this rule, until the cure is complete. As soon as the organ is 
apparently restored to its normal condition treatment should be dis- 
continued, as a retrogression may otherwise occur. Overtreatment is 
certainly to be avoided. At each sitting the inflations are repeated 
from two to four or six times, with not enough pressure to cause pain 
or bright redness of the membrana flaecida. The vessels along the 
upper portion of the handle of the mallet often become injected even 
after gentle inflation. 

For the removal of the fluid contents of the tympanic cavity that 
do not disappear after inflation, a number of years ago the author 
devised a method that he has never seen mentioned except once, which 
was in a journal article that appeared about three years subsequent 
to his publication. The patient inclines his head forward and a little 
toward the opposite side, and practices an experiment that just reverses 
the Yalsalvan method. He closes the nose with his thumb and fore- 
finger and draws the air from the naso-pharyngeal space down into his 
throat. This method exhausts the air of the cavities above the phar- 
ynx and sucks the secretions from the Eustachian tube and middle 
ear into the throat: thev can be seen immediately afterward trickling 
down the side of the pharynx from the region of the tube-orifice. 
When the drum-head was perforated I have utilized this same method 
to draw medicated solutions from the external meatus through the 
middle ear and tube into the pharynx or nose. This thoroughly 
washes these surfaces with the remedies used. 

The treatment outlined for this disease does not mention the 



88 TREATMENT OF HYPERTROPHIC CATARRH OF THE MIDDLE EAR. 

catheter for the reason that, since the introduction of the modern 
improved instruments for treating the ear, nose, and throat with com- 
pressed air, the catheter is not often a necessary instrument, The 
improved inflator (Fig. 26) will inflate the middle ear in almost every 
instance in which it is properly employed. This saves the patient 
suffering, prevents injury to the inflamed walls of the tube, and 
avoids the possibility of infection, as the inflator is not carried into 
contact with the mucous surfaces as the catheter is. (See remarks on 
catheterization in Chapter IV.) 

If my method of autoaspiration of the tympanic cavity through 
the Eustachian tube should not suffice on account of the thick, tena- 
cious character of the secretion, paracentesis of the drum-head should 
be made under antiseptic precautions, as already described in the treat- 
ment of acute inflammation of the middle ear. After opening the 
membrane, air is thrown through the tube and tympanum so as to 
eject all discharges from them into the external meatus. There need 
be no fear that any permanent damage may be done by the para- 
centesis, for it will undoubtedly close in a few days. The expelled 
secretions should be removed by cotton on a carrier and the canal 
left dry. The meatus is then closed with absorbent cotton. Should 
fluid accumulation recur the membrane may have to be reopened, 
even repeatedly in exceptional cases. A few days or weeks of this 
treatment generally' suffice for a cure, but the more obstinate con- 
ditions require months for their eradication. 

The treatment for associated rhinitis and pharyngitis will be 
found under those headings. 

Medicinal applications may be advantageously employed when 
simple air-douches fail to reduce the tumefaction and hypersemia of 
the lining tympanic membrane. A number of years ago the author 
introduced the use of purified liquid vaselin, and later camphor-men- 
thol in lavolin, for treating tubal and tympanic catarrh. The physio- 
logical action of camphor-menthol is given in Chapter XVIII. Sprays 
of these remedies are thrown into the tube and middle ear by means 
of the improved inflator. The sponges it contains are saturated with 
the liquid and, by applying the cut-off of the compressed-air tube to 
the inflator, a jet of the remedy is projected into the tube and tym- 
panum. I have since learned that Charles Delstanche, of Brussels, 
preceded me in the use of liquid vaselin in the middle ear. This 
treatment is usually best followed by the massage otoscope in obsti- 
nate cases. After the treatment has effected all that is possible we 



TREATMENT OF HYPERTROPHIC CATARRH OF THE MIDDLE EAR. 89 

have observed that patients maintain their improvement and even con- 
tinue to progress, after changing their residence from low and damp 
surroundings to a high, dr} r , and equable climate. 

Operations on the drum-head are treated of in Chapter X, and 
hygienic measures are considered in the treatment of acute rhinitis, 
or corvza. 



CHAPTER IX. 
DISEASES OF THE MIDDLE EAR, CONTINUED. 

Sclerosis, or Adhesive Inflammation, of the Middle Ear. 

Synonym. — Sclerotic tympanitis. 

The line of demarkation cannot always be distinctly and un- 
mistakably drawn between the early adhesive and the late hyper- 
trophic middle-ear catarrh. The latter may merge by imperceptible 
degrees into the adhesive variety, and the sclerotic processes may pass 
through their initial stage during the activity of the hypertrophic 
inflammation. But the most intractable forms of deafness — involv- 
ing ankylosis of the ossicles, especially immobility of the stapes, and 
labyrinthal involvement — characterize the adhesive, or sclerotic, ca- 
tarrh. 

Pathology. — While this form of catarrh may affect the whole 
lining membrane of the middle ear, it may be circumscribed and 
limited to the tissues surrounding the oval and round windows. A 
distinguishing characteristic is an insidious interstitial inflammation,, 
induration, and chronic thickening of the tissues, or sclerosis. But 
in a considerable proportion of cases there is progressive atrophy;, 
pale, thin membrane, and calcareous degeneration. Again, there may 
be an excessive proliferation of connective tissue, filling and even 
obliterating the cavity of the attic and of the oval and round fenestra? 
and binding down the ossicles to such a degree as to impede or pre- 
vent their normal movements. Bands connecting the membrana tym- 
pani and ossicles together alter the normal tension of the conducting 
apparatus, resulting in varying degrees of deafness and perversion of 
hearing. These bands become the seat of calcareous degeneration,, 
with the result of binding the ossicles to each other, to the mem- 
brana tympani, and to the tympanic walls with rigid or bone-like 
bridges. The drum-head is often the seat of these chalky deposits,, 
which generally appear like miniature drifts of snow in crescentic 
forms below and about the mallet (Fig. 46 and Plate I). 

Ankylosis of the ossicles takes place either by increased fibrous- 
tissue formation or by bony growth. Ankylosis is infrequent between 

(90) 



SCLEROTIC CATARRH OF THE MIDDLE EAR. 



91 



the anvil and stirrup, but is frequent between the mallet and anvil, 
and between the stirrup-plate and the border of the oval window. 
Indeed, we may have these ankyloses combined with bands of adhe- 
sions binding- the membrana tympani and ossicles together, and hy- 




Fig. 46. — Semilunar chalky deposit in front of the handle 
of the mallet. (After Politzer.) 

pertrophy and calcareous degeneration of the membrane of the round 
window. The natural filaments and bridges of mucous membrane con- 
necting the crura of the stirrup with the border of the oval foramen 
(Fig. 47) favor the fixation of this bone when fibrous or calcareous 
changes occur. Calcification or ossification may take place in the 




Fig*. -47. — Xiche of the fenestra oralis,, with the crura of the stapes. 
in the normal ear of an adult. Net-work of bands extending from the 
neck of the stapes to the walls of the niche, c, head of the stapes; 6?, s, 
crura of the stapes. (After Politzer.) 



ligamentous ring of the stirrup, and bony union with the oval window 
may result. Calcareous deposits have been found in the malleo-in- 
cudal joint, and I have suspected that in patients of a uric-acid diath- 
esis deposits of urate of soda might take place in these joints as well 



92 SCLEROTIC CATARRH OF THE MIDDLE EAR. 

as in other articulations. Bichey believes sclerosis to be closely re- 
lated to progressive arthritis deformans. In a conversation with Pro- 
fessor Politzer upon this subject, the author asked him if he had ever 
discovered such a deposit, but he replied that he had not, since, in 
his method of preparing specimens, any evidence of such deposits 
would be destroyed. Christopher J. Colles believes that a rheumatic, 
gouty diathesis has undoubtedly much to do with the obstinate char- 
acter of many cases of middle-ear trouble, especially the chronic mid- 
dle-ear catarrh. 

The Eustachian tube may participate in a diffuse form of this 
inflammatory process and become stenosed, but it is often normally 
permeable and even abnormally patulous. 

Etiology. — The hypertrophic, or secretive, inflammation of the 
middle ear predisposes to the adhesive or dry sclerotic form. The 
latter is noticeably hereditary and can be often traced to the father 
and his family or to the mother and hers. The brothers or sisters 
are often more or less afflicted. General diseases that are destructive 
of tissues and exhausting to the general strength promote this form 
of middle-ear catarrh. Chronic catarrh of the nose and throat and 
excessive indulgence in alcohol and tobacco-smoking bear a close 
causative relation to sclerosis. Yet the author cannot place the em- 
phasis on smoking that some authors do, since he has seen the worst 
examples of this disease in both women and men who were not at 
all addicted to the use of tobacco. 

The hypertrophic form might be spoken of as a disease of child- 
hood, during which it is very common; but sclerosis is a disease of 
middle and old age. In my experience it nearly always is seen in 
persons over 30 years of age, rarely in those younger, and mostly in 
those much older. It generally affects both ears, and, although 
patients in the early stage often aver that only one ear is troublesome, 
the surgeon should never fail to examine both — and the naso-pharynx 
as well. 

Symptomatology. — Tinnitus aurium constitutes the most dis- 
tressing symptom. Patients often declare that if the noises only can 
be conquered they will be satisfied, whether their hearing can be im- 
proved or not. These are variously described as high-pitched ring- 
ing, like that produced by quinine or by boxing the ears; like roar- 
ing or rushing of waters; chirping of crickets; hissing; the singing 
of a tea-kettle; escaping steam; sighing of the winds, etc. The in- 
tensity of the tinnitus is usually in proportion to the loss of hearing, 



SCLEEOTIC CATAEEH OF THE MIDDLE EAE. 93 

until the miserable subject can hear little or nothing but the inter- 
minable storm of confusing and crazing noises, compared to which the 
clanging and crashing of the kettle-drums and cymbals in a Wagnerian 
overture are a heavenly melody. 

The suffering is increased by cold, wet, and windy weather; tak- 
ing cold, alcoholic drinks, speaking or reading aloud, and anything 
that produces excitement or depression of the strength or spirits. 
Sometimes a startling loud sound rings out suddenly, without any 
apparent cause, like a stroke from a hammer on a high-pitched bell; 
then gradually it dies away until it is lost in the confusion of other 
less intense subjective sounds. Often patients declare that the noises 
are not in the ear itself, but refer them to the side of the head and 
even to the occiput. Most frequently, however, the author has noticed 
that they place the tips of their fingers over the hearing-centre in 
the brain when locating the sounds outside of the ear. They some- 
times believe it is possible for others to hear these noises if the ob- 
servers ear were to be placed close to their own. I have known some 
patients to insist that crickets or other creatures were in their ears,, 
and that they must be removed, when the sounds were entirely sub- 
jective. 

On the other hand, persons with discipline of mind and strong- 
will suppress mentally these besieging enemies of consecutive thought 
and intelligent action until they are scarcely conscious of their pres- 
ence while engaged in active occupations. But when the mind be- 
comes disengaged for a time in a quiet place, or more especially when 
there is occasion for listening intently to a speaker, the noises seem 
to surge back into the presence of the conscious mind with furious 
intensity. Very nervous individuals are so overwhelmed by this symp- 
tom that they may succumb and part with their reason. 

Severe or continuous pain is not a symptom of sclerosis, but sharp^ 
stinging pains lasting but a few seconds or minutes are not uncom- 
mon. Great sensitiveness to certain sounds and to concussions of the 
air exists. The slamming of a door may be painful, owing to the noise 
or to the concussion, or both. With abnormal tension of the sound- 
conducting apparatus and impaction of the foot-plate of the stirrup 
in the oval window, there is an increase of labyrinthal pressure and 
more or less headache, vertigo, and sense of tightness or pressure in 
the head, although the patient may not be able to particularize or 
localize it unless he possesses a very observant mind. 

The hearing is generally much worse in sclerosis than in hyper- 



94 SCLEROTIC CATARRH OF THE MIDDLE EAR. 

trophic catarrh, and shows less variation either with or without treat- 
ment. The hearing may vary during the day. One individual hears 
better in the morning and worse in the evening. Another hears 
better until, perhaps, 4 o'clock in the afternoon, when the hearing 
becomes dull, to remain so the rest of the evening. Another hears 
worse in the morning until he has his breakfast and boards the train 
for the city, when the jar of the car appears to produce a commotion 
in his ears, his Eustachian tubes open to the admission of air to the 
tympanic cavities, and at once he hears better and experiences a sense 
of clearness and relief in his ears. In the noise he hears better, even 
better in some instances than those with normal hearing. A locomo- 
tive engineer under my care said he could hear better than his com- 
panions when his engine was in motion, and that his employers, for 
whom he had worked several years, did not suspect his impairment of 
hearing. He managed to give them no opportunity of conversing 
with him except in a noise. The vibrations of his engine communi- 
cated motion to his conducting apparatus, which then conveyed sound- 
waves that were too feeble of themselves to institute these movements. 

Another interesting fact has come under my observation. A 
long-standing catarrh of one ear had so impaired its usefulness that 
the patient did not consciously depend upon it. The better ear had 
lost its usefulness through an attack of epidemic influenza, when the 
patient was obliged again to depend on the previously worse ear. 
Then it was found that, although sounds could be distinguished in it, 
they could not be understood. Words could be heard, but not in- 
terpreted, on account of long disuse of the organ. It became neces- 
sary to practice with the various words in common use until they 
could be distinguished from each other and correctly interpreted. 
The process was comparable to learning a new language, but it was 
accomplished. 

In this case the sounds of the C and C forks, 128 and 256 vibra- 
tions, were perceived by air and bone conduction at the correct pitch 
by both ears. The C" and C", 512 and 1024 vibrations, were always 
heard at the proper pitch with the right ear, and by bone with the 
left ear; but by air with the left they were perceived as a half-tone 
above the real pitch. Fork C"", 2048 vibrations, was heard with each 
ear faintly, when almost touching the mouth of the meatus, but not 
by bone conduction with either ear. The patient distinguished with 
difficulty between this fork and the subjective ringing, which was 
of the same pitch. 



SCLEROTIC CATARRH OF THE MIDDLE EAE. 95 

The hearing for speech is the most affected, while hearing for 
music, etc., may remain fair. The musical composer, Emerson, was 
afflicted with greatly impaired hearing for speech: but he mastered 
the trying requirements of a great musical conductor. Hearing bet- 
ter in a noise, paracusis Willisii, is characteristic of this form of ear 
disease. By the simple expedient of causing sound- vibrations in the 
air by means of such a device as an electric hammer, or an electric 
bell with the gong removed, or a spring and ratchet in an electric 
motor or fan, one with this form of deafness will be able to conduct 
a business conversation when otherwise he could not without a con- 
versation-tube or horn. It is not, however, the commotion of the air 
produced by the fan-wings that aids hearing, but the sound-waves 
that keep the drum-membrane and ossicles in vibration. 

Bone-conduction is not so likely to be normal in this as in the 
hypertrophic process. It is often much diminished or altogether ab- 
sent for the highest and lowest notes. But it should not be forgotten 
that bone-conduction begins to show reduction after the thirtieth 
year. The hearing for the highest tones and the very low notes is 
diminished or lost in the order named. Certain notes in the medium 
register may also be unperceived, which indicates labyrinthal im- 
plication. 

Diagnosis. — The appearances of the drum-head vary greatly. 
There are thickening and retraction of the membrane (Figs. 48 and 
49 and Plate 1) with foreshortening of the mallet-handle in some cases 
(Fig. 45), while in others there is atrophy with chalky deposits, or, in 
other instances, a membrane of quite normal appearance. The ad- 
hesive process may be confined to circumscribed areas on the surface 
of the inner tympanic wall which inspection does not reveal. The 
Eustachian tubes may have been involved during the early stages, while 
later in the history of the disease they may be freely permeable. The 
massage otoscope will show any adhesion of the membrane to the inner 
wall (Fig. 50) and the amount of mobility that the mallet may have 
lost. It will also reveal bands of adhesion that may exist superficially 
behind the drum-membrane if the latter is pressed by the air inward 
so as to lie against and embrace these bands. "When there is normal 
freedom of motion of the hammer during the massage, it is certain 
that its articulation with the anvil and the articulation of the latter 
with the stirrup cannot be ankylosed: but the stirrup may be an- 
kylosed in the oval foramen. In such cases, with a normal-looking 
drum-head, one must be very guarded in his prognosis, for they are 
sometimes intractable and hopeless. 



96 TEEATMENT OF SCLEKOTIC CATARRH OF THE MIDDLE EAR. 

Prognosis. — From what has been said it will be naturally in- 
ferred that brilliant results may not be expected from treatment in 
a large proportion of cases of sclerosis of the middle ear. The out- 
look will be more favorable if the disease is not of long standing, if 
tinnitus is either absent or only an occasional symptom, if the hear- 




Fig. 48. — Marked retraction of the drum-head. (After Politzer.) 

ing is not seriously impaired, if bone-conduction is normal, and if 
treatment produce a decided amelioration of the symptoms. The 
reverse of these circumstances renders the prognosis unfavorable. 
Age, general health, sanitary surroundings, personal habits, heredity, 
and occupation must also enter into the account. 




Fig. 49. — Circumscribed depressions in the anterior-inferior quadrant 
of the left drum-head. (After Politzer.) 



Treatment. — We can hardly speak of treatment in this form of 
middle-ear catarrh as being generally curative. We must candidly 
admit that in otology, as well as in other branches of medicine, there 
are maladies that sometimes baffle the most skillful practice of our 
art. All that we can hope to accomplish is to stay the progress of a 
persistent process. A patient under my treatment at the present time 



TREATMENT OE SCLEROTIC CATARRH OF THE MIDDLE EAR. 97 

said, when informed that he had lupus: "Then I will have nothing 
done." I replied: "If a wolf were biting you, would you not want 
me to take him off?" So in the case of sclerosis; it is our duty to 
interpose every possible obstacle to the development and progress of 
the pathological process that is attended with such distressing and 
deplorable results. If no more can be accomplished than to relieve 
the never-ending din of harassing noises that incessantly bombard the 
brain, it is worth the while. This confusing strife of discordant 
sounds, this concentration of all the overtones in nature focused on a 
sensitive being almost deprived of normal, intelligible, sweet-toned 
sounds, often test the tension of the mind to the breaking-point. 

The most common and simple treatment is the injection of air; 
but, in order to accomplish enough movement in the membrane and 
ossicles, to stretch or break bands of adhesions and to overcome anky- 




Fig. 50. — Circumscribed adhesion of the membrana tympani to the 

promontory underneath the handle of the mallet, a, 

point of adhesion. (After Politzer.) 



losis, more force must be applied than is recommended in the simple 
hypertrophic catarrh. While the latter may require with a patulous 
tube no more than an atmosphere, or 15 pounds, or less, we have em- 
ployed 60 pounds and even more pressure without producing much 
impression on these old, hardened, thickened, leathery drum-heads. 
This is not mentioned as an intimation to the unpracticed that they 
should use so much pressure, but 30 pounds' pressure is often required 
in this affection to produce any motion in the ossicles. Wiirdemann 
advocates similar treatment, with the air-regulator. When the foot- 
plate of the stirrup is not ankylosed, some transitory giddiness may 
be occasioned by this pressure, but in case it is immovable we cannot 
look for dizziness to occur from inflation. If we can obtain sufficient 
movement in the stirrup to produce momentary vertigo it brightens 
the outlook, for it probably indicates that bony union has not yet 
taken place between the base of the stirrup and the border of the oval 



98 TREATMENT OF SCLEEOTIC CATARRH OF THE MIDDLE EAR. 

foramen. If inflation and massage are followed by an amelioration of 
the symptoms, improved hearing, abatement of the tinnitus, relief of 
a sense of pressure, and a feeling of clearness in the head, then the 
prospect is encouraging. If a few weeks of daily treatment should 
make no perceptible impression of any kind, the opposite is true. But 
the massage treatment on alternate days is a most important auxiliary 
to politzerization, and we can now profitably enter into its detail. 

The author's massage otoscope (Fig. 8) possesses some advantages 
over others. As compared with Siegle's pneumatic speculum, the au- 
thor's otoscope is (1) self-illuminating, not requiring the aid of a hand- 
mirror or forehead-mirror, the light being accurately focused on the 
drum-head; (2) it affords a magnified view of the field; (3) it can be 
operated in a smaller canal than will admit the speculum; (4) the 
bright reflection of light into one's eye by the glass of the speculum, 
the black, background of which converts the glass into a mirror, is 
.avoided in the otoscope by the proper and unvarying relations and 
the color of its various parts. The directions for manipulating this 
instrument are given in Chapter II. 

By alternately rarefying and condensing the air in the auditory 
meatus the amount of mobility in the drum-head and the chain of 
bones may be determined under brilliant illumination and a magni- 
fied view. If ankylosis of the joints of the ossicles, or if bands of ad- 
hesions between the bones and the walls of the tympanum exist, the 
handle of the malleus will be seen to be impeded in its movements, or 
it may remain fixed, while the membrane about it may be quite 
flaccid, and respond to the rarefaction of air by bulging outward about 
the mallet-handle (Fig. 41). When the membrane is greatly thick- 
ened in patches or contains calcareous deposits, these portions will 
be seen to resist the action of the vibrating column of air, while nor- 
mal parts and areas of thin, cicatricial tissue that indicate the loca- 
tions of former perforations may respond readily to the experiment. 
In cases where the drum-head is very thick, or where the ossicles are 
bound down by adhesions to the walls of the tympanum, no per- 
ceptible movement may be obtained at first, but decided improvement 
often follows a persistent use of the pneumatic treatment. 

In obstinate cases the progress may be hastened by making press- 
ure directly upon the processus brevis by means of a probe covered 
with a soft-rubber tip or Lucas's pressure-probe. Stiffness in the joints 
may be overcome in this way so as to facilitate the action of the 
otoscope. One should press gently on the process until the handle 



TREATMENT OF SCLEROTIC CATAEEH OF THE MIDDLE EAE. 99 

moves, then retract the probe until the malleus resumes its former 
position, press again, and so repeat the movement three or four times. 
Then the pneumatic principle of the otoscope should be applied until 
one is satisfied that the advantage gained will not be lost. The 
mallet should be moved until the patient experiences a sensation of 
movement or sound. The utility of passive motion, or massage, in 
the treatment of stiff joints and atrophied tissues is well recognized 
in general surgery. The application of the same principle to the 
same conditions in aural surgery is also attended with beneficial re- 
sults. Charles Delstanche, of Brussels, has also devised an excellent 
massage instrument. 

The pressure-probe which I devised in 1886, and which was men- 
tioned at the meeting of the American Medical Association in 1888, 
has been superseded by a much better one (Fig. 51) devised by my 
good friend Professor Lucse, of Berlin. It consists of a delicate shank 
set parallel to its hollow handle by a right-angle deviation, so as to 




Fig. 51. — Lncae's pressure-probe. 

bring the operator's fingers out of the field of vision. The distal ex- 
tremity terminates in a cup lined with soft fibre that fits over the 
short process of the mallet. The handle contains a delicate spiral 
spring surrounding the proximal end of the shank so that pressure 
on the short process and release of pressure should produce a rebound 
or to-and-fro excursion of the hammer-handle without removing the 
•cup from the process. This method is painful and causes congestion 
of the membrana fiaccida, but is often beneficial. Direct pressure on 
the line of the short process is the most effective on the stirrup. If 
treatment by inflation and massage produce redness along the malleal 
plexus of vessels, extending over the greater part of the membrana 
fiaccida, it should not be used further for that treatment. 

We have found the best results from a systematic plan somewhat 
as follows: For the first week or two lavolin is injected into the mid- 
dle ear by means of the improved inflator (Fig. 26) on Monday. 
Wednesday, and Friday, always preceding the ear treatment with the 
necessary cleansing and medication of the nose and throat. On the 



100 TREATMENT OF SCLEROTIC CATARRH OF THE MIDDLE EAR. 

intervening days the massage otoscope is used sufficiently to obtain 
as nearly as possible the normal mobility of the ossicles, or until the 
hyperemia, mentioned before, is produced. On the second or third 
week the treatments are gradually separated by intervals of two, three, 
or four days. The lavolin conduces to the softening and rendering 
pliable the adventitious tissues in the middle ear. When stimulation 
is desired, or the patient or surgeon is in doubt as to the entrance of 
the jet of lavolin into the tympanic cavity, 6 or 10 drops of sulphuric 
ether added to the lavolin in the sponges contained in the inflator will 
produce stimulation and a sensation of coolness followed by a glow of 
warmth in the ear, thus demonstrating its presence in the tympanic 
cavity. Eichey advocates the iodine-vapor inflations and iodized cot- 
ton in the external canal. Dunclas Grant uses a self-inrlator charged, 
with chloroform. 

If it should be desirable to produce the effect of camphor-men- 
thol on the lining membrane of the tympanic walls without carrying 
a perceptible amount of the menstruum into the cavity, this can be 
accomplished by substituting the dilator (Fig. 19) for the inflator,. 
with a 3-per-cent. solution of camphor-menthol in lavolin. For the 
physiological action of camphor-menthol see Chapter XVIII. It is 
but proper to remark that the beneficial results sometimes afforded 
by this method are even more surprising to the surgeon than to the 
patient. 

Formerly the author followed in the footsteps of his predecessors 
in the employment of fumes from resublimed iodine crystals with 
which to douche the middle ear, but so little perceptible good and so 
much irritation attended its use that it has had little place for this 
purpose in his practice for a number of years. Pilocarpine hydro- 
chlorate, in 1- and 2-per-cent. solutions, is much used for injections 
into the middle ear through the catheter. Generally 6 to 10 drops 
of the weaker solutions are injected three times a week for four or 
six weeks. The medicine and catheter must be sterilized, and used 
while warm. These injections are best alternated with the massage 
treatment, The author has tried solutions of citrate of lithia, a very 
soluble form, by injections through the Eustachian tube, in the hope 
that if deposits of urate of sodium were present in certain gouty pa- 
tients, and if the ankylosis of the ossicles were due to the presence 
of this deposit as in other joints, of the same individuals, it might be 
dissolved out. Carbonate of lithia is known to accomplish similar- 
results. The effect was nil. 



TREATMENT OF SCLEROTIC CATARRH OF THE MIDDLE EAR. 101 

A considerable variety of other solutions and volatile medicaments 
have been projected into the middle ear for the relief of sclerosis, but 
it would be a waste of time and space to enumerate most of them. 
Many are inert and others are positively harmful. The injection of 
fluids through the Eustachian catheter and tube is attended with irri- 
tation of the tube and tympanum unless accomplished by exception- 
ally skillful and gentle hands — and no others should attempt it. Pos- 
sibly a little tympanic irritation may prove beneficial, but the prob- 
abilities are in favor of its proving harmful. If hyperemia is desired 
it can more easily and safely be produced by the prolonged use of 
the massage otoscope and Lucas's pressure-probe. The Yalsalvan 
method produces congestion of the tympanic tissues, and for that 
reason patients ought not to be taught or allowed to practice it. They 
receive a certain amount of temporary relief; consequently they prac- 
tice it not once or twice a day, but repeatedly, many times a day, until 
the membrana tympani loses its tension, becomes relaxed and re- 
tracted, and no more relief is had. Such a case is now under ob- 
servation. He began practicing autoinflation ten years before coming 
under my care. He was advised by a prominent anrist to practice the 
Valsalvan experiment, and he has grown progressively worse during 
all that time. It is an interesting incident, which should serve as a 
warning, that he had been under the care of three aural surgeons, 
two of whom are eminent, without the fact of his being addicted to 
this habit being disclosed. This is only one example of numerous 
instances which could be cited as illustrating the unwisdom of placing 
in the hands of patients methods for self treatment that are likely to 
result in more harm than good. The sole fact that the patient was 
worse after ten years of autoinflation is not mentioned as proof that 
the retrogression was due to the practice. The opinion is based on 
the results of studies of these cases, the details of which cannot be in- 
corporated with this observation. 

The use of the phonograph, vibrometer, and other expensive in- 
struments that produce sound-waves of speech, or musical vibrations 
that are conveyed to the ears by rubber tubes inserted into the ex- 
ternal canals, have been much vaunted by ill-advised laymen; but 
experimental investigation only confirms what a familiarity with the 
principles involved presages: their utter inutility. During a discus- 
sion of this subject at the meeting of the First Pan-American Medical 
Congress, the otologists present, including the distinguished Professor 
Politzer, concurred in these conclusions quite generally. 



102 TREATMENT OF SCLEROTIC CATARRH OF THE MIDDLE EAR. 

It is worthy of attention that the treatment with the improved 
inflator filters all the air and fluids before they reach the ear. All 
are forced through the finest quality of medicated sponges, which 
offer a resistance to the air-current of about four pounds. This fact 
should be given proper consideration in every treatment, and all the 
instruments must be kept scrupulously clean and disinfected in order 
not to commit the unpardonable sin of infecting a patient. A 5-per- 
cent, solution of carbolic acid is best for this purpose. 

Massage of the external meatus has been a part of the author's 
treatment for a considerable time, although he has refrained from 
mentioning the method until convinced of its undoubted value. After 
observing the beneficial effects of massage on other organs it oc- 
curred to me to try the effect of the application of the same prin- 
ciples to the external auditory canal in the atrophic condition accom- 
panying sclerosis. The result was not only that patients experienced 
a sensation of relief and freedom from itching, but the middle ear 
appeared to make better progress than when the massage was omitted. 

The method pursued is as follows: Cotton is twisted quite firmly 
on the slender silver holder (Fig. 9) so that it will not easily slip off; 
this is smeared with vaselin or a o-grain yellow-oxide-of-mercury oint- 
ment made with vaselin; then the anointed cotton is rubbed or 
stroked upon the canal-walls in a circular direction while the holder 
is rotated on its axis in the direction that will prevent the cotton from 
becoming disengaged. This friction is continued only long enough 
to thoroughly cleanse the skin and stimulate the circulation. The 
ceruminous glands, which are generally in an atrophied state in this 
disease, are aroused into greater activity. The skin, which is dry, 
scaly, and often eczematous, assumes a healthier appearance, and the 
effect upon the process of nutrition does not appear to be confined to 
the external canal, but seems to extend to the tympanic cavity. 

Care must be taken to avoid touching or irritating the drum-head, 

and the cotton must not be allowed to slide off the end of the holder so 

-as to allow the latter to abrade the skin. The author has not seen 

this method pursued or suggested by others, yet experience deprives 

him of the temerity to advance the claim to originality or priority. 

How long shall treatment be given? Only so long as improve- 
ment continues. If treatment is protracted much beyond the time in- 
dicated, it may be followed by an actual retrogression. Too much 
treatment is pernicious. When improvement takes place and a state 
is reached in which the benefit remains stationary, despite all efforts 






TREATMENT OF SCLEROTIC CATARRH OF THE MIDDLE EAR. 103 

for a reasonable time, then treatment had best cease. The patient 
should he discharged with proper instructions for the care of himself, 
and for his return should he begin to lose the gain already made. In- 
deed, these unfortunates must be gently, but candidly, informed that, 
so long as life's burden bears upon them, just so long they will suffer 
the necessity of repeating their journeys to the aurist whenever 
relapses occur. The invariable question "How long must I be 
treated?" every otologist has to answer. The average length of -time 
required varies from one to three months. Often the patient will 
remark that his head feels clearer and the noises have diminished or 
changed in character, which are favorable indications. If but one ear 
is affected, its early treatment may prevent the other from following in 
the same route. Or if both are affected, if they have not become too 
seriously involved, we may be able to arrest the progress of the dis- 
ease and preserve, if not improve, the present state of hearing. 

The application of the faradic current for ten minutes at a time 
daily for several weeks has appeared to exert a beneficial effect in 
certain cases. I have designed electrodes (Fig. 77) adapted to the con- 
centration of the current in the ears, because the older ones diffused 
the electricity over the side of the head. The tips of the chamois- 
covered electrodes are wet and covered with a little moistened cotton, 
inserted into the auditory canals, and buckled in place. Then the 
cables connecting the electrodes with the battery are attached. In 
this manner the patient is relieved of the tiresome holding of the 
electrodes in place. However, we do not attach great importance to 
electricity in this disease. 



CHAPTEE X. 
DISEASES OF THE MIDDLE EAR, CONTINUED. 

Opeeatiye Teeatment of Tympanic Scleeosis. 

The author has devised an ossicle-vibrator (Fig. 52) for the pur- 
pose of breaking up adhesions in the middle ear and ankylosis of the 
ossicles. It consists of a shaft of steel armed with two little levers at 
the distal end, and fashioned at the proximal extremity to fit into the 
angular handle of the middle-ear instruments. It is used in the fol- 
lowing manner: An incision is made through the drum-head close 
to the anterior border of the hammer-handle and parallel with it from 
the short process to its tip under cocaine anaesthesia. Then the end 
lever, which is curved for the purpose, is carried through this slit and 
behind the mallet, when the handle falls between the two little levers. 






Fig. 52. — The author's ossicle-vibrator. 

They are then slipped along upward, embracing the handle, until the 
stronger part of the bone is reached and the levers fit the handle some- 
what closely. Now the retracted hammer-handle is slowly and very 
gently drawn upon until it is felt to move, or until the adhesions are 
felt to give way, and to the extent of bringing the handle to its nor- 
mal position. The gentlest care must be taken or the adhesions may 
give way very suddenly with a jerk and the mallet might possibly be 
dislocated, or the handle might be fractured, especially if the instru- 
ment were allowed to slide downward upon the weaker portion of the 
handle. We have not known these accidents to attend the use of 
my instrument, but one can conceive that they are within the range 
of possibilities. Again, a patient has become pale just as the adhe- 
sions yielded to the traction, and nearly fainted. This was probably 
due to the disturbance of the intralabyrinthal fluid as exaggerated 
(104) 



OPERATIVE TREATMENT OF TYMPANIC SCLEROSIS. 105 

motion was effected in the stirrup. Some most remarkably beneficial 
results have followed the use of this simple method of mobilization of 
the ossicles. No harm has been known from it. After making the 
incision and before introducing the vibrator, it conduces to the com- 
fort of the patient to instill a few warm drops of an 8-per-cent. 
cocaine or eucaine solution. 

Incision of the posterior fold of the drum-head is indicated when 
there is a great sinking inward of the membrane, with foreshortening 
of the mallet-handle, and exaggerated prominence of the short process, 
with a stretched appearance of the membrane about it. This condi- 
tion, associated with serious impairment of hearing, and head noises 
that are unimproved by the treatment already detailed, calls for this 
simple operation. The section is best made about midway in the folds 
(Fig. 53) and the knife (Fig. 57, No. 2) is made to cut from above 




Fig. 53. — Section of the posterior fold of the membrana tympani. 
(After Politzer.) 



downward, with care that it is not carried deeper than is required to 
sever the fold. Otherwise the chorda tympani (Fig. 54) may be 
severed, producing paralysis of taste. Although the author has made 
such sections frequently, lie has never known this to follow, but such 
results are reported. Patients generally observe a sense of relief from 
pressure, clearness in the head, diminution of subjective noises, and 
sometimes improvement in the hearing. In the class of cases in which 
we have mostly practiced this operation we have not been able to fol- 
low up the results for years, but have known the benefit in a few to 
persist for several years. In others of a worse type the improvement 
has been transient. 

Multiple incisions of the drum-head have proven beneficial in 
some instances. In 1886 the author reported the results of a series of 
cases to the meeting of the American Medical Association, from which 



106 OPEEATIYE TREATMENT OF TYMPANIC SCLEROSIS. 

we quote: "For the purpose of making a crucial test of the efficacy 
of this procedure, the writer has made it the last resort in those that 
afforded no real hope for relief from any other treatment. Per- 
haps the propriety of operating on those patients that seemed to 
promise no results might be questioned, were it not for the fact that 
in nearly all of them there was an unexpected improvement and that 
no unfortunate consequences followed the operation. The cases 
chosen to operate on were far more hopeless than those with chronic 
suppurative inflammation. The consideration that the former respond 
so little to our efforts, while the latter are so amenable to treatment 



Fig. 54. — Internal surface of the left membrana tympani. a, head of 
the malleus; 1), neck of the malleus; c, tendon of the musculus tensor 
tympani and anterior fold of the membrana tympani; d, inferior extremity 
of the handle of the malleus; e, anterior portion of the membrana tym- 
pani; f, chorda tympani and posterior fold of the membrana tympani; g, 
incus; h, short process of the incus; i, long process of the incus. (After 
Politzer.) 

with inflations, cleansing, peroxide of hydrogen, boric acid, bichloride 
of mercury, etc., with the result of not only arresting the disease, but 
of improving the hearing, has led me to seriously reflect upon the 
advisability of establishing the suppurative process in sclerotic inflam- 
mation of the middle ear. In three cases only in my practice has this 
condition followed the procedure under discussion, and the results 
in the series of cases reported were satisfactory, especially when it is 



OPERATIVE TREATMENT OF TYMPANIC SCLEROSIS. 107 

considered that they were the most unpromising and had proven the 
most intractable to the usual methods of treatment. But, as re- 
marked above, this experimental work, which was carried out mostly 
in dispensary practice, did not afford opportunities to follow up the 
results for a number of consecutive years. The simple incision, of 
course, closed in a few days, but the tension of the drum-head appar- 
ently was restored to more nearly the normal." At a recent time 
(April, 1898) one of these cases came under my observation again, 
showing that the really brilliant results obtained by this method 
twelve years ago have persisted to the present. 

Another method that the writer has since pursued with consider- 
able success was the excision of areas of the drum-head, usually tri- 
angular in shape (Fig. 55). Under cocaine triangular flaps were made 
with the apex above, then the attached base was severed, removing 




Fig. 55. — Triangular resection of the drum-head. (After Politzer.) 



this piece of the membrane entirely. It was sometimes easiest, after 
incising the two sides of the triangle, to grasp the apex with delicate 
forceps in one hand while the base incision w T as made with the other. 
The improvement in some patients in whom there was no labyrinthal 
disease was very gratifying, and in private patients the possibility of 
maintaining the aperture for a considerable time was demonstrated. 
In one instance it had remained open a year and a half when the 
patient removed from the State. A peculiar experience was had with 
the other ear. The first operation afforded so much improvement 
that he requested that the same operation be performed on his right 
ear. It was done, and a slight, muco-purulent discharge followed, but 
soon ceased. While the discharge lasted, the hearing was consider- 
ably improved and the tinnitus relieved. After the discharge ceased 
the hearing began to diminish, when he expressed regret that the ear 



108 EXCISION OF THE MEMBRANA TYMPANI AND OSSICLES. 

had not continued moist. This led me to anoint it with warm, pure 
vaselin, but when it was removed a few days afterward the very large 
perforation was entirely closed with cicatricial tissue. 

The removal of sections of the drum-membrane may prove other- 
wise advantageous. It affords accessibility to the tympanic cavity for 
the instillation of various remedies and the destruction of the adhe- 
sions, and it reveals whether the entire resection of the drum-head 
would improve the hearing. In case the membrane is so thickened 
and sclerosed and infiltrated with calcareous deposits as to preclude 
the possibility of its responding to any except extraordinary sound- 
waves, and the labyrinth is not involved, the opening of a window 
in the drum-head will admit sound to the stirrup and to the round 
window and prove whether the entire absence of the membrane would 
prove remedial. If the adhesive process has not ankylosed the stirrup 
in the oval window nor invaded the round window, vibrations can 
reach the labyrinth if the barrier to their admission be removed. The 
writer has employed this test to determine whether excision of the 
entire drum-head would afford successful results. 

Division of the tensor tympani tendon is not much in favor among 
American aurists. The indications for it are not very clearly defined, 
and the appearances that suggest the shortening of this muscle — re- 
traction of the membrana tympani and foreshortening of the mallet- 
handle — are also just as characteristic of the presence of membranous 
folds and bands of adhesion. The results of tenotomy have been either 
so unsatisfactory or so positively detrimental that the operation is not 
encouraging. Greene and Pomeroy operate preferably with a blunt- 
pointed knife curved on the flat to sever the tensor tympani. 

EXCISION OF THE MEMBRANA TYMPANI AND OSSICLES. 

This operation for sclerosis is a subject concerning which there 
is probably less unanimity of opinion among otologists than upon any 
other. While a few American aurists, especially Burnett, Sexton, 
Blake, and Jack, have been enthusiastic advocates of the operation, 
and some others have followed their lead for a time, the majority ap- 
pear to have receded to a more conservative position. At the meet- 
ing of the section of Otology at the Tenth International Medical 
Congress in Berlin in 1890 the Continental leaders in this specialty 
expressed themselves in very conservative terms on the subject. Sev- 
eral years ago the writer, through the columns of the Journal of the 
American Medical Association, invited all who had performed this 



EXCISION OF THE MEMBRANA TYMPANI AND OSSICLES. 109 

operation to communicate the results to him for the purpose of pub- 
lishing a collection of experiences that would afford a just estimate of 
the average value of this operation. The responses were so few and 
so unsatisfactory as to force the conclusion that the operation was 
either little practiced or was disappointing. There is probably little 
or no diversity of opinion concerning the utility of the operation in 
suppuration of the middle ear, especially when there is ossicular 
necrosis; but as practiced for sclerosis there has been so much division 
of opinion and sad, disappointing experiences reported during the 
past ten years that candor requires that the subject be treated with 
reference to the ill as well as the good results. A number of cases 
have been under my observation upon whom the operation has been 
performed by surgeons both East and West, with the effects of pro- 
ducing a suppuration of the middle ear, destroying the hearing, ap- 
parently intensifying the noises, and producing more or less vertigo. 
The writer has had under treatment a physician from a far-western 
State whose ossicles were removed from one ear by a noted aural 
surgeon several years ago. All the ill results enumerated followed 
the operation, and, although the hearing was two inches for the watch 
before the operation, that ear has been totally deaf ever since, and 
the opposite ear has seriously deteriorated. This is a fair type of 
numerous similar instances that have come to my personal knowl- 
edge, and under the observation of other physicians who have been 
kind enough to report them to me. 

Out of six cases operated upon by a young aurist, and reported 
by him at a recent meeting of Western specialists, the results were 
unfortunate in four. In one under observation at the present time 
(August, 1898) the operation was followed by total deafness, sanguino- 
purulent discharge, and facial paralysis that treatment has failed to 
benefit. 

B. M. Behrens {International Medical Magazine, May, 1897) re- 
ports his experience as follows: "Up to the present time the radical 
operation of removing the drum-head and malleus has been performed 
on 34 cases, of which 30 have given very little improvement or none 
whatever." 

Wiirdemann had the courage to report several similar results at 
the meeting of the American Medical Association in 1892. It is 
worthy of mention that nearly all of these unfortunate cases were 
operated upon by specialists in eye and ear diseases; so that the 
results cannot be attributed to a want of familiarity with the subject. 



110 OPERATION FOR EXCISION OF THE OSSICLES. 

It is not our purpose to inveigh against this procedure as an opera- 
tion, but to emphasize the necessity not only of the utmost precision 
and gentleness in operating, but also the most painstaking prelimi- 
nary examination and experiments to determine the possibility or 
otherwise of beneficial results. For example, if the hearing-tests 
demonstrate that the labyrinth is involved in the disease, the inutility 
of the operation. is established. If no improvement follow a resection 
of a portion of the drum-head so as to admit sound-waves to the 
fenestras leading to the internal ear, no help can be expected from 
excision of the whole membrane. We do not lose sight of the fact 
that, by removing the drum-membrane and the two larger ossicles, 
we are afforded access to the stirrup so as to mobilize it. Some ad- 
vantage certainly is to be conceded to this measure, although mo- 
bilization of the stirrup is not as simple an act as one might believe. 
Even with every vestige of the membrane removed, the stirrup is 
situated so high that a good view of it is difficult to obtain, and it 
is easy to dislocate when it is not ankylosed. 

OPERATION FOR EXCISION OF THE OSSICLES. 

The ear should be prepared by syringing with a warm solution 
of bichloride of mercury, 1 to 1000, and the instruments should be 
immersed for three minutes in boiling soda-water. For several years 
past the author has used ether to the exclusion of chloroform, in- 
structing the anaesthetizer to administer only so much as is absolutely 
necessary to secure quiet and freedom from suffering. Cocaine anaes- 
thesia is not as effective as ether. After removing debris of any nature 
from the canal, it is dried and closed with absorbent cotton until the 
operation commences. If ether is used, the patient must occupy a 
recumbent position. We have found it convenient to use tables of 
sufficient height to bring the patient's ear opposite the eyes of the 
operator while the latter is sitting (Fig. 95). A brilliant illumination 
is needed. We have used mostly the Argand gas-lamp and light- 
condenser (Fig. 5) or the sixty-candle-power incandescent gas-burner. 
One will have a clearer view of the field of operation if the room is 
darkened so that no light penetrates the operator's eye except that 
reflected from the ear-cavity. 

The instruments necessary (Fig. 56) are a paracentesis-knife (No. 
2): a blunt-pointed bistoury (No. 1); two angular knives, right and 
left (^s T os. 4 and 5); two ossicle-hooks, right and left (Fig. 57); a 



OPERATION FOR EXCISION OF THE OSSICLES. Ill 

pincette (Fig. 58); a dozen slender cotton-carriers armed with cotton; 
a quart of hot, sterilized water, and a syringe. 

The operation proceeds as follows: The drum-head is incised 
with knife rTo. 2 near the periphery, behind the short process of the 
mallet. Into this opening the brunt-pointed knife (Xo. 1) is inserted 



Vjl 



i5 



i3 



32 



CT~~fe 




Fig. 56. — ^Middle-ear instruments and handle. 

and carried first below, then sweeping the lower and the anterior 
attachments until the roof is reached; then this attachment is severed 
until the whole circular incision is completed, ending at the first 
entrance. The knife is best carried first from above downward, for 
the reason that less haemorrhage is likely to obstruct the view than 
if the more vascular membrana flaccida were first cut. There is less 
haemorrhage also if the knife is kept a little way from the periphery 



Fig. 57. — The author's ossicle-hook. 

of the membrane. Xow the angular knife is used to separate the 
articulation of the anvil and stirrup (Fig. 59). The anvil is extracted 
by aid of the hooked probe, and the attachments of the mallet are 
then divided, when it is brought away with the pincette. Stacke de- 
taches the auricle and removes the integumentary canal first. 

The operation is a very short one, requiring but a few minute? 



112 OPERATION FOR EXCISION OF THE OSSICLES. 

ordinarily if there is not much haemorrhage or if the adhesions are 
not embarrassing. Eapid use of the cotton-carriers, which should be 
kept prepared by a nurse, will keep the field quite clear; but in case 
of considerable bleeding the syringe and quite hot, sterilized water 
can be brought into requisition. It is difficult to avoid severing the 
chorda tympani in this operation, but the resulting paralysis of taste 
is of short duration. The ear-cavity should be dried after bleeding 
has ceased, covered with a layer of aristol from the small powder- 
blower (Fig. 34), and the canal closed with iodoform gauze. While 
there is considerable reaction in some cases, followed by discharges of 
a muco-purulent character, in others there is little or no disturbance. 
The patient should be kept quiet, and his diet restricted until healing 




Fig. 58.^— Politzer's pincette. 

takes place. By properly restricting the diet, both before and after the 
operation, there is less tendency to regeneration of the drum-head. 
The latter occurrence is quite frequent. In the case of the physician 
just spoken of there is a false drum-head which we have not removed,, 
for the reason that no possible good could come of it. 

In another case of a very robust man from Kansas the writer 
removed the third adventitious membrana tympani, at his request. 
In the spring of 1893 a surgeon had removed his drum-head and 
mallet. In seven days after the operation he says the drum-head had 
been reproduced. This was removed, and in seven days more the sur- 
geon said that another had closed the tympanum. A third operation 
was had, and in fourteen days another drum-head had formed. Two 



OPERATION FOR EXCISION OF THE OSSICLES. 



113 



years afterward the patient came to me with the request that this 
remaining fourth drum-head with which nature had supplied him 
be removed. He suffered from great tinnitus and uncomfortable 
sensations of pressure, etc. Examination revealed labyrinthal involve- 
ment and the procedure was advised against. But, notwithstanding 
the assurance that no improvement was to be expected, the patient 
insisted upon the operation, with the hope that it might afford some 
relief to the tinnitus and pressure-symptoms. Therefore I removed 
the drum-membrane and anvil at the Post-graduate Medical School 
and Hospital, June 21, 1895, and cauterized the periphery of the 




Fig. 59. — Vertical section of the external meatus, membrana tympani, 
and tympanic cavity, a, cellular spaces in the superior wall of the meatus 
connected with the middle ear; 6, roof of the tympanic cavity; c, inferior 
wall; a, tympanic cavity; e, membrana tympani; f, head of the malleus; 
g, handle of the malleus; li, incus; i, stapes; A', Fallopian canal; I, fossa 
jugularis; m, apertures of glands in the external meatus. (After Politzer.) 



drum-head so as to completely destroy the whole circular attachment. 
A few days afterward I found the stirrup dislocated, and removed it. 
Xo unfavorable symptoms followed; the membrane has not been re- 
produced, and the slight discharge following the operation soon ceased. 
The ear has remained in good condition ever since, but, although the 
patient imagined himself better, I could discern no improvement. 
The tinnitus and other symptoms were neither removed nor consid- 
erably improved. The patient thought he could hear, but accurate 



114 OPERATION FOR EXCISION OF THE OSSICLES. 

tests proved the contrary. This case is instructive in showing that 
thorough electrocauterizing the peripheral attachment of the mem- 
brane will prevent its regeneration. We do not often employ this 
cautery in the ear on account of the great heat generated in such a 
minute inclosed space, but the chromic acid has too superficial an 
effect to accomplish the purpose. 

The reference to these unfavorable cases, — and I might cite others 
who have come under my care, one of whom is the most distinguished 
of American editors, — is not for the purpose of condemning the 
operation itself, for I believe that these unfortunate results are at- 
tributable either to an unwise selection of cases or to unforeseen acci- 
dents attending the operation. For example: Why should two inches 
of hearing for the watch be exchanged for total deafness, vertigo, etc.? 
What could have happened to cause destruction of the facial nerve? 
The results point toward an injury to at least one of the fenestrae 
opening into the labyrinth. But the reverse of this picture presents 
some excellent and even brilliant results. Some cases that have proved 
intractable to the usual measures have yielded to this; but these are 
the ones in which the labyrinth has not been involved, and the adhe- 
sive process has not destroyed the usefulness of the stirrup and the 
membrane of the round window, and in which excision of a small 
section of the membrana tympani would demonstrate the possibilities 
of the operation. Barclay, Sexton, Burnett, Blake, and Jack favor 
excision of the ossicles. Gleason (Atlantic Medical Monthly, March 
23, 1895) severs the incudo-stapedial articulation to improve hearing 
in sclerosis. 

Mobilization of the stirrup has been practiced with favorable 
results, especially by Jack; but the crura of the stirrup are so exceed- 
ingly delicate and fragile that they are quite likely to break on apply- 
ing side-pressure to them or on traction with the hook. This ma- 
neuvre is not in favor with otologists generally. After the membrana 
tympani has been removed for sclerosis the conditions are most favor- 
able for mobilization. The probe can then be introduced alongside 
the stirrup and pressure exerted in all directions to break up adhesions 
and effect mobility. The hook can then be engaged in the apex of 
the converging legs of the bonelet and drawn upon until slight motion 
is had. But if the adhesion give way suddenly, the stirrup will be 
dislodged or extracted unless great care is exercised. 

Excision of the ossicles for persistent suppuration is a common 
practice, especially in the case of caries and necrosis of these bones 



OPERATION FOR EXCISION OF THE OSSICLES. 115 

or of the walls of the tympanic cavity. Great cleanliness must pre- 
cede these operations, which can more easily be accomplished under 
eucaine or a 20-per-cent. solution of cocaine than in dry catarrh. 
The writer has often operated under these anaesthetics without any 
difficulty, especially when the patients were possessed of considerable 
self-control. The same instruments and methods are employed as in 
the operation for sclerosis. If much curetting of the bone is neces- 
sary, a general anaesthetic (ether) had better be used. 

Out of twenty-two cases of stapedectomy reported by Blake there 
was only one improvement, and in this the fixation of the stapes was 
not complete. Some became worse after the operation, both as to 
hearing and tinnitus. In five cases vertigo came on and persisted. 
Stapedectomy is now disapproved of by Blake, Cozzolino, and Gelle. 



CHAPTEE XL 
DISEASES OF THE MIDDLE EAR, CONTINUED. 

Chbostic Suppubatiye Inflammation of the Middle Eak. 

Synonym. — Chronic suppurative tympanitis. 

This is a common sequel of acute suppuration and full of im- 
port to the afflicted patient. While the laity, and unfortunately certain 
members of the medical profession who are not well informed upon 
the consequences of the disease, minimize its importance and advise 
that it be let alone and that children will outgrow it, the patient's life 
may pay the penalty of its neglect. The disease may outgrow the 
patient. The close relations of the tympanic and cranial cavities ought 




Fig. 60. — Extensive destruction of the drum-head. (After Politzer.) 

to suggest to the mind of every thoughtful physician the importance 
of prompt and skillful interference with the progressive destructive 
ravages of a suppurative process. It is not self-limited; it does not 
tend toward resolution, but toward dissolution, and no trifling make- 
shift is pardonable. 

Pathology. — The whole tympanic cavity is usually affected, the 
mucous membrane being hypertrophied and reddened, or yellowish 
and leathery in appearance. It seems unnecessary to remark that a 
perforation in the drum-head always exists, and in cases of long stand- 
ing the opening is likely to be quite large and to afford some view 
of the interior of the cavity (Figs. 60 and 61 and Plate I). 

The membrana tympani is rarely completely destroyed, and in 

(116) 



CHKONIC SUPPURATIVE INFLAMMATION OF MIDDLE EAE. 117 

those instances in which the destruction is quite extensive (Fig. 62) 
the memhrana naccida usually remains. The rupture of the mem- 
brane takes place most frequently in the lower posterior or anterior 
quadrant, but may he found in Shrapnell's membrane, — a very un- 




Fig. 61. — Pear-shaped perforation of the drum-head. (After Politzer.) 

favorable location with reference to drainage. If the perforation 
appear above the short process of the mallet, we suspect necrosis of 
this bone. The instances are not infrequent in which the whole lower, 
or tense, membrane is destroyed, while the loose membrane from the 
short process upward is intact. The hammer-handle projects down- 
ward, free from any membrane except perhaps a border on each side 




Fig. 62. — Perforation of the posterior half of the right drum-head. 
Behind the mallet is the projecting, yellowish-gray promontory; above it 
the long crus of the incus lying free and the posterior eras of the stirrup. 
(After Politzer.) 



of the upper half of the handle (Figs. 63 and 61). This gives an 
excellent view of the inner wall of the cavity and of the long leg of 
the anvil and possibly the leg of the stirrup if they are present. 

When the ossicles participate in the necrotic process, the anvil 
is the first to succumb in three-fourths of the cases. This is to be 



118 CHRONIC SITPPUBATIYE INFLAMMATION OF MIDDLE EAR. 

accounted for by its poorer blood-supply. Its nutrition is easily cut 
off by pressure in the upper part of the tympanum. 

In long-standing suppuration, and more especially when the de- 
struction of the drum-head is extensive, there occurs a shedding of 




Fig. 63. — Destruction of the inferior half of the membrana tympani, 

laying bare the promontory and niche of the round 

window. (After Politzer.) 



superficial epithelium of the middle-ear membrane, which takes on 
an epidermic character; so that it presents the appearance of skin 
rather than mucous membrane. This probably is brought about by 
an extension or growth inward of the epidermis of the canal through 
the perforated membrane, or cholesteatoma. 

While the perforations of acute suppurations generally close spon- 




Fig. 64. — Large perforation of the right drum-head. The handle of the 

mallet is free and the long crus of the incus and the niche of 

the round window are visible. (After Politzer.) 

taneously after the discharge ceases, they more often remain more or 
less permanently open after the chronic suppuration is cured. In a 
long course of suppuration the destruction of the membrane is far 
more extensive than in the acute or transitory variety. Yet we often 



CHRONIC SUPPURATIVE INFLAMMATION OF MIDDLE EAR. 119 

come upon elderly people who show unmistakable evidences of ex- 
tensive loss of tissue of the membrane that has been repaired by 
nature — large sections in the lower posterior or anterior quadrant, or 
in both, that consist of translucent, thin, cicatricial tissue, surrounded 
by the ashy-gray, leathery tissue of the old membrane. Many of these 
people are unconscious of ever having had a discharge from the ear, 
but upon investigation the fact may be established that it occurred 
beyond their remembrance, probably during childhood. 

The disease may extend to the labyrinth, although it is not of 
frequent occurrence. It far more often invades the mastoid antrum 
and cells. If we recall the position of the antrum behind the middle 
ear, and the connection of these cavities by the aditus ad antrum, 
and then their relative positions when the patient lies upon his back, 
we shall appreciate how the fluids in the tympanum may drip through 
the aditus and enter the antrum. It is like the changing of the 
battery-fluid from one part of a Kidder tip-battery cell to the other 
by turning the cell upon its axis. It is apparent from these con- 
siderations that mastoid disease is a logical consequence of middle- 
ear suppuration. 

Etiology. — From what has already been said it is evident that 
this affection is only an extension of the acute suppurative process 
in most instances, the causes of which are enumerated in Chapter 
VIII. Neglect of an acute disease generally results in a chronic one. 
A tubercular or syphilitic habit of body predisposes to this condition. 

Symptomatology. — The presence of a purulent discharge issuing 
from a perforation in the drum-membrane is a simple matter to dis- 
cern. The pus may be abundant or very scant. The author has 
under treatment a case of more than twenty years' standing in which 
not more than a drop or two will exude in a day. For a few days 
or a week there may be no discharge, and then a foul-smelling exuda- 
tion is found. In other instances there is not enough purulent dis- 
charge to run out of the canal, but instead it dries in scales or yellow 
crusts on the walls of the canal. As these crusts of inspissated pus 
work toward the mouth of the canal they cause itching and conse- 
quent annoyance. 

The hearing may not be seriously impaired. It does not de- 
teriorate so generally nor to such a degree as in sclerosis. Still, the 
hearing is greatly affected in occasional cases. Crusts may form over 
a small perforation, obstructing the discharge and impairing hearing; 
but patients do not often complain of subjective noises. 



120 CHRONIC SUPPURATIVE INFLAMMATION OF MIDDLE EAR. 

Granulations (page 127) often form on the border of the perfora- 
tion and over the surface of the intratympanic membrane (Fig. Go 
and Plate I). Large, cherry-red, spongy granulations sometimes may 
cover the inner wall like a cushion. They are sensitive and bleed 
readily. 

Polypi (page 127) occasionally spring from the membrane and 
occupy the canal. A single polypus often fills the canal and extends 




Fig. 65. — Destruction of inferior half of the drum-head. Globular granula- 
tions on the inner wall of the middle ear. (After Politzer.) 



to its mouth. We have seen them grow to such proportions that the 
pressure upon the canal-walls interfered with the circulation of the 
end projecting from the mouth of the canal to the extent that its 
color was livid or black and suggestive of gangrene. We also have 
multiple aural polypi of luxuriant growth and of the form of a minia- 
ture cauliflower. These are usually of a bright-red color. If the pus 
in which the polypus is macerating is carefully removed without irri- 
tating the polypus, the latter presents sometimes a very pale, ex- 



•™m*sr 



Fig. 66. — Slender middle-ear probe. 

sanguinated surface, but upon friction it assumes a bright-red color 
and bleeds upon being touched. Mucous polypi are more commonly 
met with than the fibrous variety. 

Carious bone (page 129) is to be suspected whenever granula- 
tions or polypi exist. The bent probe (Fig. 66) may detect denuded 
bone in the tympanic cavity. The anvil (Fig. 78) is occasionally lost, 
and, if the external wall of the aquasductus Fallopii, containing the 



TEEATMENT OF CHKOXIC SUPPUKATIOX OF MIDDLE EAR. 121 

facial nerve, is imperfect or necrosed, facial paral) r sis of the same side 
will occur if the pressure is sufficient, or the nerve itself may par- 
ticipate in the inflammation. William Sotier Bryant calls attention 
to the fact that there is sometimes a perforation in the outer bony 
wall of the aqueduct, establishing a direct communication with the 
middle ear. If necrosis of bone is present, the odor of the discharge 
is generally offensive, even when care is taken of cleanliness. With 
neglect of the discharge it may become very foul, even when there 
is no osseous necrosis. Invasion of the labyrinth is ushered in by 
sudden dizziness, deafness, and nausea. Fortunately this is a very 
rare complication. 

Diagnosis. — If the description given be borne in mind, there is 
no difficulty in deciding upon a case of chronic suppuration of the 
middle ear. The long-standing discharge from a perforation in the 
drum-head makes the case clear. 

Prognosis. — This is a progressively destructive disease. Its tend- 
ency is not to spontaneous resolution. "While many attacks may ap- 
pear to get well of themselves, as long as the diseased condition re- 
mains, just so long recurring attacks will succeed each other. With 
every fresh cold, back comes the flux. The disease continues, though 
no discharge may make its appearance for a time, and the patient is 
lulled into a false sense of security. A slight exciting cause sets up 
another exacerbation of the existing inflammation. Moreover, the 
natural tendency of this trouble is toward the bone. The mucous 
membrane of the middle ear answers the purpose of a periosteum, and 
the intimate relation of these structures jeopardizes the integrity of 
the osseous tissue when destructive processes are going on in the 
membranous lining. It has also been shown that mastoid suppura- 
tion is an offspring of middle-ear inflammation. The same may be 
said of phlebitis and sinus-thrombosis, meningitis, subdural abscess, 
pyaemia, and abscess of the brain. Only with proper treatment is 
the prognosis good. 

Treatment. — More brilliant results are obtained here than in the 
adhesive catarrhal form of inflammation. The first object is absolute 
cleanliness. This is best obtained by syringing the ear with at least 
a quart, or more if necessary, of sterilized water, or mercuric bichlo- 
ride solution, 1 to 5000, as warm as is comfortable to the patient. 
Unless a considerable quantity is used, all of the inspissated, greasy 
accumulation often found in a neglected suppurating ear is not re- 
moved. As much force as can be easily borne is generally required at 



122 TREATMENT OF CHRONIC SUPPURATION OF MIDDLE EAR. 

the first cleansing, to remove all the discharges from the ear. The 
water need not be thrown with so strong a current as to produce 
giddiness or nausea. The continuous-flow syringe, like the alpha 
(Fig. 33), is the most satisfactory, as it admits of most perfect control 
over the temperature of the water and the force of the current. The 
stream is directed a little toward the roof of the canal, rather than 
directly in a line with its axis, so as to return along its floor. The 
patient, if an adult, can hold some conveniently-shaped receptacle 
j)ressed closely against the side of the neck just beneath the lobule 
to catch the returning solution. The water once injected into the ear 
must under no circumstances be re-injected. We have found people 
(physicians!) committing that act. Crusts, inspissated pus, and cer- 
umen not expelled by the water can be removed with cotton on the 




Fig. 67. — The author's large powder-blower for use with a 
hand-bulb or compressed air. 



carrier or a blunt probe. Delstanche has devised a tympanic syringe 
to inject the attic. 

After cleansing thoroughly with the syringe, the ear is inflated 
(Fig. 26) so as to eject any possible secretion remaining in the Eu- 
stachian tube or middle ear. The parts are then dried with absorbent 
cotton, and a coating of aristol or nosophen (page 81) is dusted over 
the surface of the middle ear with the small powder-blower (Fig. 34), 
or boric acid with the large powder-blower (Fig. 67). Aristol is ex- 
cellent on account of its antiseptic, anaesthetic, and cicatrizant prop- 
erties. It never causes pain and does not interfere with the hearing 
by clogging the canal or impeding the movements of the drum-head 
and ossicles. If the discharge does not show perceptible decrease in 
the course of a week or two, it is advantageous to substitute boric 



TREATMENT OF CHEOXIC SUPPUEATIOX OF MIDDLE EAE. 123 

acid for the aristol or to throw a coating of boric acid over the aristol 
dressing. This can be done without dislodging the latter, for it sticks 
tenaciously to the surface of the tissues. This adds the drying effect 
of boric acid to all of the excellent qualities of aristol, and consti- 
tutes an ideal treatment for such individuals as we haye mentioned 
who haye an idiosyncrasy against boric acid. AVe haye met a few- 
such instances with this disease, although they are oftener encoun- 
tered among the acute cases. After the first few treatments of this 
kind it is adyisable to resort to an entirely dry method, relying on 
the absorbent-cotton driers, inflation, and the powders, for cases 
often do much better with the dry than with the wet method. The 
discharges often cease after a few treatments, and occasionally after 
the first one. The results of painstaking methods are more surprising 
to the surgeon than to the patient, who may haye been harassed for 
long years with annoying discharges. 

One of the most effective methods consists in packing iodoform, 
or nosophen, gauze quite firmly against the suppurating surface if 
it can be reached, more especially upon a granulating surface. If the 
iodoform disagree, other medicated or sterilized gauze must be sub- 
stituted. The dressings must be frequently repeated when the dis- 
charge is copious. 

Many other remedies are commonly used, but it is the author's 
purpose to giye only what years of experience haye proyen to be the 
most efficacious and to inform the practitioner upon the relative 
merits of those that have been given extensive trials. Some will be 
mentioned merely for the purpose of saving the reader's time in ex- 
perimenting with the useless. 

Iodoform in fine powder is useful when the odor of the discharge 
and other signs indicate the presence of dead bone; otherwise it is 
not preferable to aristol or nosophen, and its disgusting odor is usu- 
ally very objectionable to fastidious people. The old-time remedy, 
silver-nitrate solution, was formerly extensively used in my clinics, 
but for many years we have not employed it. Having tried it in solu- 
tions varying in strength from 1 per cent, to a saturated solution, it 
became apparent that its remedial qualities in this disease were in- 
ferior to remedies that were less objectionable. The blackening of 
everything it touches renders it especially disadvantageous in private 
practice. Zinc sulphate exerts too little influence to merit our con- 
fidence. Salicylic-acid powder, highly recommeuded a few years ago, 
has proven, in my hands, a total failure in this disease. Moreover, 



124 TREATMENT OF CHRONIC SUPPURATION OF MIDDLE EAR. 

the violent irritation of the nares and the attacks of sneezing which its 
unavoidable inhalation produces during the insufflation would pre- 
clude the possibility of its employment were it not otherwise im- 
potent. Europhen proved unsatisfactory in this disease. We have 
persisted in experimentation with it alone and combined with aristol, 
and are forced to the conclusion that the total value of europhen- 
aristol lies in the latter ingredient. Indeed, the aristol alone is more 
potent. After extended trials with yellow pyoktanin no appreciable 
effect could be observed in arresting the discharge, and the same is 
true of dermatol, alumnol, and iodol. 

Let us suppose now that we have a more intractable type of sup- 
puration. The mucous membrane lining the tympanic cavity appears 
very red, suggestive of the glow of dull, red-hot iron; it is much 
thickened and tumefied; the drum-head partakes of the same char- 
acteristics, is very sensitive to the touch, and shows rhythmic pulsa- 
tions. These characteristics obtain in a small proportion of old cases. 
It is difficult to adapt the dry method of treatment to such condi- 
tions, for the touching of the drum-membrane with the cotton to 
absorb the discharges is productive of great pain. It is best then to 
irrigate and allow all the water to run out; then hydrozone, which is 
a stable 30-volume dioxide, or peroxide, of hydrogen (H 2 2 ), is 
warmed slightly, only sufficiently to make it comfortable to the ear, 
and is used to fill the canal while the head is inclined to the opposite 
shoulder. Or, better still, the patient lies upon the opposite side. 
Warming the dioxide to the temperature of the body, or even ten de- 
grees above, does not impair its efficacy, as we have often demon- 
strated. It is allowed to remain in the ear until effervescence ceases. 
This requires about five or ten minutes, according to the amount of 
pus present and the purity of the remedy. It must not have a strong 
acid reaction or it will cause pain, and it should contain not less than 
fifteen volumes of available oxygen. The hydrozone decomposes pus- 
corpuscles, during which action free oxygen is liberated to exert its 
germicidal property upon bacteria. Besides this the active efferves- 
cence that takes place dislodges the accumulations, and its mechanical 
action brings to the surface materials that even syringing fails to 
dislodge, — for example, aristol that may have remained from a pre- 
vious treatment. This boiling out of the middle ear appears to cleanse 
the attic even better than the intratympanic syringe, and no un- 
pleasant results have ever attended my use of it. 

In suspected retained discharges in the attic or mastoid antrum, 



TREATMENT OF CHROXIC SUPPURATION OF MIDDLE EAR. 125 

especially when the perforation is too small to admit of free drainage, 
it should be enlarged, as already described on page 77. But there are 
frequent instances in which the discharge does not diminish after 
thorough efforts at cleansing, disinfecting, and medicating. This 
may be owed to the fact that the means employed do not remove 
all of the retained secretions, and there is a consequent failure of the 
medicaments to reach all of the diseased surfaces. The author has 
devised an instrument to meet this condition. It consists of an im- 
proved miniature air-pump (Fig. 6S), containing a metallic valve that 
does not get out of order, fitted to a glass reservoir. The metallic 
tip of the reservoir should be covered with a section of soft-rubber 
tube so as to permit of its being fitted with firmness and nicety into 
the external meatus. Gentle traction on the piston-ring exhausts the 
air in the middle ear and accessory chambers and causes the ejection 
of any discharges within them into the canal, whence they are re- 
moved with the cotton absorbent. After the piston is moved the 




Fig. 68. — The author's ear-aspirator. 

whole length of the cylinder once or twice the instrument is removed 
and the canal inspected. Then, after drying it of the secretions 
brought to view, the process is repeated two or three times. AVhen 
no more discharges can be drawn from their hiding-places, it is safe 
to conclude that all have been evacuated. The traction need not be 
rapid nor strong enough to occasion discomfort or the exudation of 
any blood; although, if the latter occur, no harm is done, for the 
discharges are the more thoroughly swept away and the tissues are 
stimulated. The instrument is held in such a way as to grasp both 
air-pump and receiver in the fingers of one hand at the same time, 
so as to prevent their being separated while the pump is in action. 
In order to prove the value of this simple device in numerous cases, 
I have given the most thorough treatment by the old methods with- 
out diminishing the discharges, and then have resorted to this treat- 
ment in addition to the old methods, with the result of stopping the 
flux promptly. In such cases, after cleansing as much as possible by 
syringing, the dioxide, etc., I have applied the aspirator and have 



126 TREATMENT OF CHRONIC SUPPURATION OF MIDDLE EAR. 

clraAvn an astonishing quantity of discharges that must, judging from 
their amount and character, have been stored in the mastoid antrum 
and cells, and these cases have recovered without mastoid operations. 
McBride {Edinburgh Medical Journal, June, 1895) opens the 
mastoid process and middle ear to cure chronic suppurative inflam- 
mation, and Jones (Liverpool Medico-Chirurgical Journal, July, 1894) 
advocates excision of the ossicles. 



CHAPTER XII. 
DISEASES OF THE MIDDLE EAR, CONCLUDED. 

Sequels of Middle-Ear Suppuration. 

graxulatioxs. 

The presence of granulations (Plate I) in the middle ear or on 
the drum-head protracts the cure of a suppurating process. If they 
are small and not very extensive, they can be made to shrink up and 
disappear by the use of alcohol and nosophen. At first it is advisable 
to dilute the alcohol one-half. In the event of no pain being caused 
by that it can be used stronger, and if the patient easily bear it the 
full strength should be employed. The period in the treatment for 
using it is just after the cleansing process is finished, and the alcohol 
should remain in the ear ten minutes or longer. After it runs out 
the granulations that appeared very red before its application are 
blanched to a pale-gray color after the contact of the alcohol for a 
sufficient length of time. Then the treatment should be completed 
with the powders, as described in Chapter XL Tincture of iodine is 
effective when applied to the granulation by the cotton-carrier, only 
enough being used to touch each granulation, but not to run over the 
surrounding surface. "When the granulations are very large and 
abundant, suggestive of beginning polypi, these are best removed by 
the curette (Fig. 80) under a warm, 20-per-eent. solution of cocaine 
or an S-per-cent. solution of eucaine. The bleeding is stopped by 
pressing a pledget of cotton against the curetted surface for a few 
minutes, a few drops of cocaine solution is used on them, and then 
the alcohol as before. Chromic acid may also be employed as de- 
scribed in the next paragraph. 

POLYPI. 

Two forms of aural polypi occur: the mucous and the fibrous. 
Suppuration cannot be cured so long as a polypoid growth is pres- 
ent. This is best removed under cocaine or eucaine by a polypus- 
forceps (Fig. 69) or the snare found in the middle-ear case (Fig. 70). 

(127) 



128 



AUEAL POLYPI. 



It requires less skill to use the forceps. The polypus should be de- 
tached as close to the attachment of its pedicle as possible, and, the 
method being so simple and identical with the same procedure in 




Fig. 69. — Politzer's polypus-forceps. 



other fields of surgery, it would be superfluous to enter into the details 
here. The bleeding ceases soon and can be stanched as described in 

Then cocaine is applied and the attachment 



treating of granulations 




Fig. 70. — The author's middle-ear case. 



cauterized with chromic acid. The loop of the flexible caustic ap- 
plicator (Fig. 71) is dipped into the dry crystals of chromic acid, and 
these are held over a small flame for a few seconds until they are 
melting. Just at the instant the crystals are fused in the form of a 



CAEIES AXD NECROSIS OF THE MIDDLE EAR. 129 

drop on the most convenient site of the loop for application the in- 
strument is withdrawn from the heat and the drop of fused acid is 
blown upon to cool it suddenly into a bead. Unless the attachment 
of the polypus is well cauterized it is likely to grow again. It can 
be removed with a fenestrated curette of good size, like the larger 
one in the middle-ear set, by placing the curette so as to engage the 
pedicle in the aperture. Then, by pressing firmly against it and 
drawing outward, it is detached and extracted. 

CARIES AXD XECROSIS OF THE MIDDLE EAR. 

"When the tympanic walls are denuded of their lining membrane, 
which is, in effect, its periosteum, the treatment requires much 
patience and persistence. After cleansing by water, hydrozone, and 
the aspirator, as outlined, a 12-per-cent. solution of carbolic acid in 
glycerin is poured into the ear. This does not require warming. 
After it has remained long enough to produce the anaesthetic effect 
of the acid — about six minutes — it is removed and replaced by a 



Fig. 71. — The author's caustic applicator on flexible shank. 

saturated solution of iodoform in alcohol. If the solution is agitated 
so that some of the powder is held in suspension, so much the better, 
for when the solution is allowed to run out after five or ten minutes 
a fine coating of iodoform powder is left covering the diseased tissues. 
This solution penetrates the diseased cavities deeply. Then the treat- 
ment is completed, as already described, for suppuration. In cases 
where denuded bone could be felt with the probe, this method has 
effected cures. Indeed, sequestra of necrosed bone may have been 
cast off and discharged with the pus, leaving the healthy bone to 
become healed over by granulation. But if dead bone be present it 
acts as a local irritant similarly to a foreign body, and must be re- 
moved with the curette before healing will take place. A foul odor, 
notwithstanding scrupulous cleanliness in the treatment, indicates the 
presence of osseous necrosis. As long as this foul odor continues the 
discharge cannot be stopped, but the disappearance of the odor is a 
very favorable symptom, as H. Gradle has shown. Persistence in 
this treatment will often remove the odor and discharge. There are 



130 



NECROSIS OF THE OSSICLES. 



occasionally persons with whom the alcoholic solution of iodoform 
does not agree. The integument of the canal becomes swollen, tender, 
and excoriated, and the toxic iodoform must give way to other reme- 
dies. The bichloride of mercury occasionally is not well borne, and 
if used in too strong a solution a similar condition ensues, and even 
ulceration of the integument. 

NECROSIS OE THE OSSICULA. 

The anvil, the first to yield to the necrotic process, is sometimes 
lost before patients apply for treatment, but when it is present and 
is diseased it should be removed. The same is true of the mallet. In 
such cases they are of no value to the patient, and only serve to ex- 




Fig. 72. — Vertical section of middle ear; drum-head in contact with 
the inner wall, a, ledge-shaped remnant of the membrane; b, c, the lateral 
portions of the cicatrix, extending from the remnant of the membrane to 
the inner wall of the tympanic cavity; d, portion of the cicatrix applied 
to the inner wall. (After Politzer.) 



cite a continuation of the inflammatory process and to hinder the 
free evacuation of the retained secretions. Their excision, if skill- 
fully accomplished, does not impair the hearing and may conserve it. 
The question of their removal in this instance is not a parallel case 
to that in sclerosis. The operation is described in Chapter X. 

Adhesions of the remnant or of cicatrices of the membrana tym- 
pani to the inner wall of the tympanic cavity may occur after the 
suppuration is cured (Fig. 72). This results in a cup-shaped de- 
pression in the drum-head. Adhesions and false membranes also 
form within the tympanum, subdividing it into several cavities (Fig. 
73). Connective tissue and chalky deposits (Fig. 74 and Plate I) 



PEEFOEATIOXS OF THE DEOI-HEAD. 131 

sometimes fill completely the middle ear. imbedding the chain of 
bones so firmly that their functions are entirely destroyed. In case 
the adhesions cause serious impairment of hearing by embarrassing 
the vibrations of the ossicles or by preventing sound-waves from reach- 
inn the labyrinth, thev can be divided or excised. Connective-tissue 




Fig. 73. — Band-like cords between the lower end of the hammer-handle 
and the stapedo-inendal articulation. (After Politzer.) 

formations and cretaceous deposits can be treated like cholesteato- 
matous masses, which are considered later. 

PEEFOEATIOXS OF THE DEOI-HEAD. 

Perforations (Plate I), if they are large, generally remain open 
and require no treatment. The edges become covered with a con- 
tinuation of the epidermis of the drum-head. The membranous 




Fig. , 4. — Central perforation of the drum-head and calcareous 
deposits. (After Politzer.) 

lining of the middle ear becomes habituated to the presence of air 
that reaches it directly through the meatus, so that it acquires a 
tolerance for it. like the nasal mucous membrane. The hearing re- 
mains better with than without the perforation, but there are ex- 
ceptional instances in which the hearing is improved by closing the 



132 DEAFNESS FOLLOWING SUPPURATION. 

perforation with cotton or a thin rubber disc. The latter exceptions 
can be treated by freshening the edges of the perforation after the 
discharge ceases, and covering the aperture accurately with a moist 
disc of sized paper. The presence of this foreign body will excite 
sufficient irritation to iucrease the circulation in its vicinity to the 
extent of causing a proliferation of cells, growth of granulations, and 
consequent closure of the opening. But the cases are rare in which 
the patient's interest is best subserved by closing the perforation, for 
the remainder of the drum-head is usually opaque, hypertrophied, or 
calcified (Fig. 74) and leathery; so that it is unfitted for transmitting 
sound-waves. With an opening through it the vibrations have direct 
access to the foot-plate of the stirrup and the membrane of the round 
window, and through them reach the perceptive apparatus. 

Artificial drum-heads should receive mention in this connection. 
We have seen a few persons who believed they were able to hear bet- 
ter with discs or cones, of soft rubber inserted so as to lie in contact 
with the membrana tympani; but the remote ill effects more than 
counterbalance the immediate apparent increase in hearing-power. 
When there is suppuration they impede the outward flow and pro- 
mote decomposition of the discharge. In any event, they act as for- 
eign bodies, giving rise to irritation and resulting increase in con- 
nective-tissue formation. This increased thickening of the tympanic 
tissues insures a still greater decrease in hearing. 

DEAFNESS FOLLOWING SUPPURATION. 

Deafness following suppurative inflammation calls for treatment 
after the suppuration ceases. Politzerization to overcome adhesions 
between the ossicles or drum-head and the walls of the tympanum 
may be practiced three or four times a week. Better still, if the per- 
foration has closed, is the method of throwing a spray of lavolin into 
the middle ear with the improved inflator (Fig. 26). The lavolin 
takes the place of the discharge, and it is commonly observed that 
the hearing is better while the middle ear remains moist. The 
lavolin is a bland, non-irritating liquid vaselin, and does not become 
rancid like oil. It softens the dried and hardened tissues, increases 
their suppleness, and promotes greater freedom of mobility. This 
injection is followed by the use of the massage otoscope (Fig. 8). 
The drum-head is caused to make a dozen or more to-and-fro ex- 
cursions, with an endeavor to approximate as nearly as possible the 



CHOLESTEATOMA. 133 

natural limits of movement. This is after the fashion of the ma- 
chinist, who first oils his machine and then works it. This method 
is best pursued on alternate days for three or four weeks, or as long 
as perceptible progress is made in improvement, and then discon- 
tinued. As long as the benefit obtained is stationary the ear had best 
be let alone. It is well to instruct these patients that when retrogres- 
sion sets in they should return for further treatment. 

Tinnitus aurium is not a very common symptom in purulent in- 
flammation, but it is an occasional sequel of that trouble. The treat- 
ment just detailed for the deafness is the best adapted for the sub- 
jective noises also. 

CHOLESTEATOMA. 

In this disease there is an excessive growth of epidermis in the 
external auditory canal and desquamation of epithelial cells in the 
middle ear. Lumps of epidermis and shiny, pearl-like, little masses 
are found, both during and after suppuration. Bezold believes them 
to be the result of an extension of epidermic formation from the ex- 
ternal canal to the middle ear. Luca? reports a case without any 
suppurative process. Yirchow believes they are true heteroplastic 
tumors. 

The epidermis of the external meatus spreads over the walls of 
the middle ear, and even invades the mastoid antrum, but the latter 
is the result of excessive proliferation of epidermis accompanied with 
exfoliation. The concretions are of a caseous appearance, containing, 
besides epithelial cells, fat-globules, bacteria, and crystals of cho- 
lesterin. 

The mastoid process is more often the seat of these masses than 
the tympanic cavity. They increase to a large size as the bone is de- 
stroyed either by advancing caries or necrosis or as the result of 
absorption due to pressure. 

The diagnosis is not difficult if the excessive formation and des- 
quamation of epidermis are noticeable in the external meatus, and 
if the epidermic masses are visible in the middle ear through a per- 
foration. Chunks of foul-smelling, gritty, cheesy particles may be 
found in the washings from the ear. The perforations are most likely 
to be found in Shrapnell's membrane, for the growth of epidermis in- 
ward is marked on the upper wall of the canal. Long-continued and 
obstinate suppuration is characteristic of this disease. The masses 
constitute a dam against the free exit of the discharges, and decom- 



134 



FACIAL-NERVE PARESIS AND PARALYSIS. 



position of pus and the growth of polypi are encouraged. This con- 
dition forms a fruitful soil for the propagation of bacteria. 

When the cholesteatoma is situated in the tympanic attic or in 
the mastoid antrum the diagnosis is difficult, if not impossible, to 
determine, unless the masses disintegrate and are evacuated during 
the cleansing treatment, or unless the mastoid cortex breaks down 
and exposes the condition present. If the diagnosis can once be posi- 




Fig. 75.— Facial paresis. Appearance the same as in permanent facial 
paralysis. The patient is photographed while laughing. 

tively made out, the question of operative measures is settled. The 
methods of treatment are found under the headings of "Chronic Sup- 
puration" and "Mastoid Operations." Bezold advises epidermic trans- 
plantations in cholesteatomatous cavities, after the Thiersch method. 



FACIAL-NERVE PARESIS AND PARALYSIS. 

Impairment or loss of function of the facial nerve is due to a 
variety of causes. The facial canal and neurilemma may participate 
in a middle-ear inflammation; ulceration and necrosis of the bone 



FACIAL-NERVE PARESIS AND PARALYSIS. 



135 



may involve the nerve: an exudate, a callus, a sequestrum, or a tumor 
may produce pressure; syphilitic or other central nervous disease may 
exist at the origin of the nerve, or traumatic injury may partly or 
wholly paralyze it. The lower branches supplying the nose, side of 
the face, and angle of the mouth are generally more affected in paresis 
from the mastoid operation than the upper branches that are dis- 
tributed to the orbicularis palpebrarum. But in some cases the fore- 




Fig. 76. — Same as Fig. 75, three months after Stacke operation and 
treatment with electricity. 



head and face are for a time seriously affected, even when the eye can 
be closed completely, but slowly, and with an effort. 

The same side of the velum palati may be involved in the paraly- 
sis. If the muscles of the side of the face and angle of the mouth 
are paralyzed, the patient cannot drink liquids without their driveling 
from the lips; he cannot innate the cheeks without the air escaping 
from the paralyzed corner of the mouth; in laughing the face is 
drawn to the unaffected side, giving a crooked appearance to the 
countenance (Fig. 75). The facial expression is entirely lost on the 



136 TREATMENT OF FACIAL-NERVE PARESIS AND PARALYSIS. 

side that is paralyzed. The inability to close the eye exposes it to 
winds, sunlight, and dust, resulting in chronic conjunctivitis. 

Recovery may be expected from paresis due to an acute inflam- 
mation of the Fallopian canal and the sheath of the facial nerve 
secondary to the middle-ear inflammation, and from slight injuries 
to the nerve during mastoid operations (Fig. 76). Paralysis, or com- 
plete loss of conduction of the nerve, resulting from caries or necrosis 
of the facial canal, or from division of the nerve during an opera- 
tion, jDresents an unfavorable prognosis. In this condition the eye 
cannot be closed. 

Dench says: "Injury to the facial nerve is not a serious acci- 
dent, function being restored in from three to five weeks, in most 
cases, under the use of the faradic current/' The author is not in 
accord with this view. If the whole calibre of the nerve-trunk is not 
affected, but only certain bundles, spontaneous resolution may occur 
and complete restoration of function in three to six months; but the 
author has never seen a case of recovery take place after complete, 
total paralysis of all its branches had occurred from injury to the 
nerve during an operation. He has seen varying degrees of inter- 
rupted transmission in the different branches of the nerve, with corre- 
sponding variations in the recovery. The eye being the least and the 
side of the face and mouth next least affected would recover com- 
pletely, while the occipito-frontalis remained powerless, giving a 
noticeable drooping effect to the eyebrow. 

On the other hand, we have had cases of paresis, affecting all the 
branches, occurring after operations for excision of the ossicles 
through the meatus, etc., recover completely after the use of the 
galvano-faradic current for three or four months. But we must make 
the distinction between paresis, or partial paralysis, and actual paral- 
ysis, which is a complete loss of nerve integrity. 

In the course of the nerve which is most exposed to traumatism 
during the mastoid operation the bundles distributed to the obicularis 
oris, the muscles of the side of the face, the occipito-frontalis, and the 
corrugator supercilii seem to lie external to the fibres composing that 
part of the anterior temporal branches that supply the orbicularis 
palpebrarum, for the latter muscle is the least affected in operative 
paresis and the first to regain its function. 

Treatment of facial paresis and paralysis depends upon the lesion 
present. If the latter is an acute inflammation with exudation, upon 
the subsidence of the inflammation and the absorption of the exu- 



TREATMENT OF FACIAL-NERVE PAKESIS AXD PAEALYSIS. 13? 

date recovery takes place. If there be pressure of the pus on an ex- 
posed nerve in middle-ear suppuration, or if a sequestrum of bone 
produce the pressure, either must be removed. If syphilis is the 
cause, iodides and mercurials must be employed on general principles. 
Sexton mentions facial paralysis due to dental irritation. 

These cases recover after a course of the iodides, pilocarpine, and 
electricity, the current being used from the primary coil of a faradic 
battery. The negative pole is applied to the ear of the affected side 
by means of the ear-electrode (Fig. 77), and the positive to the op- 
posite ear or mastoid region, then to the groups of affected muscles, 
causing perceptible, though not painful, contractions in them. Such 
a treatment should be given three or four times a week, continuing 



Fig. 77. — The author's ear-electrodes,, attached to a head-band. 

ten minutes. This prevents muscular atony or atrophy, while the 
nerve regains its tone. 

After the mastoid operation the electric current can be applied 
directly to the injured section of the facial nerve by saturating a 
pledget of absorbent cotton with sterilized water or hydrogen dioxide, 
placing it in the bottom of the wound, and connecting the ear-elec- 
trode directly with this. The other pole is then applied to the trunks 
of the several branches of the nerve distributed to the groups of mus- 
cles affected. If one is not familiar with these points he can readily 
determine them by applying the facial electrode to the opposite side, 
observing what areas need to be touched in order to contract the 
desired muscles. In Fig. 112 Xo. 1 shows the point where the elec- 
trode will afreet the infra-orbital, malar, and temporal branches of 
the facial nerve. These supply the muscles of the forehead, the 
orbicularis palpebrarum, and the muscles of the face, nose, and upper 



138 CAKIOUS PEOCESSES IK THE TEMPOBAL BONE. 

lip. No. 2 shows the point where the electric current will reach the 
"buccal and supramaxillary branches distributed to the buccinator and 
orbicularis oris and muscles of the lower lip and chin. 

CABIOUS PEOCESSES IK THE TEMPOEAL BONE. 

These do not characterize a large percentage of the cases of mid- 
dle-ear suppuration. They are sometimes due to tuberculous and other 
constitutional taints. AVhile very small areas are likely to be affected, 
they may extend to involve the wdiole temporal bone. Scarlatina is 
one of the most frequent' causes, but syphilis and typhoid fever may 
also give rise to them. The pneumatic portion forming the mastoid 
process is the most often affected. Next in frequency come the tym- 
panic w^alls and adjacent tissues. The anvil and sometimes the head 
of the mallet are attacked by the necrotic process. 

Pain is a pretty constant symptom of caries except in tuberculous 
individuals, the amount of pain being determined by the extent of 
periostitis or interference with the free discharge of pus. Other dis- 
tressing symptoms in addition to pain characterize this condition: 
dizziness, noises, nausea or vomiting, insomnia, and fever. The dis- 
charge is disgusting, often bloody and irritating. Granulations and 
polypi are commonly found, and the ossicles may be dislocated so as 
to wash out when the ear is syringed, together with sequestra of dead 
bone (Fig. 78). The meatus may be involved, — swollen or ulcerated. 
If the disease attack the inner tympanic wall, the external wall of the 
Fallopian canal may be destroyed, exposing the facial nerve to pressure 
or to the inflammatory process, resulting in facial paresis or paralysis 
of the same side. 

Exfoliation of the cochlea takes place in rare instances. Kichey 
reports two such cases. Goldstein (Annals of Ophthalmology and 
Otology, April, 1895) reports a case of exfoliation of the cochlea,, 
vestibule, and semicircular canals. A fair degree of hearing for con- 
versation with the affected ear remained. Later Euedo, of Madrid, 
reported a similar case with retention of hearing. 

Toeplitz (Archives of Otology, No. 2, 1892) reports a case of pri- 
mary labyrinthal necrosis with facial paralysis and deafness from scar- 
let fever. During the suppurative process two sections of the cochlea 
were exfoliated and removed through the external auditory canal. 

The diagnosis of necrosis or caries is not an easy affair unless it 
can be seen or felt. The probe may detect it if within reach, but 
the diseased bone may be defended by a growth of granulations form- 



CARIOUS PROCESSES IN THE TEMPORAL BOXE. 139 

ing a more or less complete carpet. Great caution is required in 
probing so as not to displace the little bones or open up the labyrinth 
to the introduction of pus. If the treatment detailed under the cap- 
tion "Chronic Suppuration of the Middle Ear" does not succeed, after 
a considerable time of persistent effort, in diminishing and finally 
stopping the foul discharge, it is safe to infer that there is a carious 
condition of the bone. Caries is especially dangerous when the roof 
of the middle ear is its seat, for it may terminate in a rupture which 
will admit the pus into the cranial cavity. When the pyramid is in- 



§># 


fp%]£" 


t\ 


1 1 


3 ' 1 * 


6 


* m 


§m * 





7 f 


f 10 // 


/I 


f 4 « 




13 


/* is- 





Fig. 78. — Sequestra of dead bone, and the ossicles. Actual size. The 
smooth surfaces of the walls of the tympanic cavity and of the meatus 
are shown in Xos. 1, 2, 3, 4, 5, 6, and 11; 13, mallet; 14, anvil; 15, 
stirrup. (Author's specimens.) 

vaded the hearing is destroyed and an unfavorable prognosis must be 
given. 

Erosion of the carotid canal may occur, or of the lateral sinus, 
with fatal haemorrhage. ' Such a case of destruction of the carotid canal 
came under my observation by the kindness of J. E. Davey, recently, 
which required ligation of the common carotid artery. Eepeated 



140 



CARIOUS PROCESSES IJS T THE TEMPORAL BONE. 



copious haemorrhages occurred from time to time, that could only be 
stopped by packing the meatus. Complete recovery followed ligation 
of the common carotid artery. 

Another method of termination is an extension of the caries to 
the cranial cavity and lateral sinus, or it may excite suppurative men- 
ingitis or phlebitis, or end in brain-abscess. A perforation of the 
inner table of the mastoid process may allow the pus to filter into 




Fig. 79. — Post-mortem section of the temporal bone, showing a perforation of 

the lateral (sigmoid) sinus at 1. Borders of sinus bounded by 

black lines. (Author's specimen.) 



the current of blood in the lateral sinus, producing pyaemia. The 
writer has such a typical specimen in his collection (Fig. 79). 

This was the case of a man with mastoiditis for whom I advised 
an immediate operation. The physician in attendance deferred the 
operation until, when it was performed, the patient was suffering 
profoundly from pyaemia. A hopeless prognosis was given. Autopsy 



TREATMENT? OF CARIOUS PROCESSES IN TEMPORAL BOXE. 



141 



revealed the perforation of the lateral sinus shown in the foregoing 
figure, through which the purulent contents of the mastoid cells were 
flowing. Fig. 114 is the same mastoid process as Fig. 79, showing 
where the fistula (No. 2) opened beneath the tip of the process and 
the attachment of the sterno-cleido-mastoid muscle, resulting 



m an 



2^S£ 



Fig. 80. — The author's middle-ear curette. 

abscess of the neck, located underneath this muscle. No. 3 shows 
the opening made by a small trephine directly into the antrum, in 
which the probe rests. No. 4 is a tuft of cotton in the external au- 
ditory canal. There is no doubt that this patient's life could have- 
been saved had the operation been submitted to when it was first 
advised. 

Treatment includes thorough cleansing and disinfecting of the 
suppurating cavities and removal of granulations or polypi, as de- 



h d i 




f 



Fig. 81. — Horizontal section of the ear. a, anterior wall of the osseous 
meatus; /), its posterior wall; c, section of the membrana tympani, of the 
handle of the malleus, and of the posterior pouch; d, promontory; e, 
ostium tymp. tubse; f, stapes in connection with the inferior extremity 
of the long process of the incus and of the tendon of the stapedius; 
(j mastoid process; li, cochlea; i, vestibule; k, carotid canal. (After 
Politzer.) 



tailed in the foregoing pages. Anodynes must be given for severe pain. 
The denuded, roughened bone, if within reach, should be scraped 
free of all carious tissue with the middle-ear curette (Fig. 80), but 



142 TEEATMENT OE CAEIOUS PEOCESSES IN TEMPOEAL BONE. 

only the most delicate resort to such procedure should be had in case 
the caries is located on the inner tympanic wall, for it is thin and 
easily perforated when carious (Figs. 81 and 101). After curetting, 
the treatment as detailed for chronic suppuration is called for. 

Sequestra are removed with ease or difficulty according to their 
size, shape, and location. Patients sometimes present pieces of dead 
bone that have become exfoliated and appear in the syringing process. 
The author has removed quite a large sequestrum from a boy 4 years 
old by means of cotton on a holder. During the examination the 
cotton used for drying out the ear was observed to become engaged 
in the angular spiculae of a sequestrum. So it was twisted firmly into 
them and drawn upon, with the result of extracting the quite large 
sequestrum completely (Fig. 78, No. 2, actual size). Other sequestra 
(actual size) from various cases are shown in the same figure. When 
the sequestra are too large and irregular to be extracted through the 
meatus without inflicting unwarrantable injury, they may be crushed 
by sequestrum forceps and removed in fragments. When an extensive 
sequestrum cannot be removed through the natural channel and sup- 
puration cannot be cured, and especially if urgent or dangerous symp- 
toms supervene, it is advisable to open the mastoid process and re- 
move as much of the posterior wall of the meatus as is required to 
extract all the dead bone. The diseased surface should then be cu- 
retted, dressed, and treated as detailed under "Mastoid Operations." 

The general condition of the patient may call for tonics and 
alteratives, which will readily occur to. the practitioner. 



CHAPTEE XIII. 

EXTEXSIOX OF EAR DISEASES TO THE CRANIAL CAVITY. 

Intracranial complications of suppuration of the middle ear 
take place in the following ways: By an extension of the carious 
process in the temporal bone to the cranial cavity, with evacuation 
of pus into the latter; by extension through the vessels and fenestras 
that penetrate the hone, resulting in purulent meningitis; by the 
formation of a subdural or brain-abscess, and by septic involvement 
of the venous sinuses, resulting in phlebitis, thrombosis, embolism, 
and septicaemia. 

Meningitis Complicating Otitis. 

Symptomatology. — Severe and continuous headache, localized or 
general, increasing in intensity and accompanied with photophobia, 
generally characterizes the onset of this disease. There are nausea 
or vomiting, sleeplessness, loss of memory, general hyperesthesia, 
dullness of intellect, and in children delirium and convulsions of the 
face (same side) and extremities. In the advanced stage opisthotonos 
may occur. The pupils are firmly contracted at first, afterward dilated 
and not responsive to bright light, but they are sometimes unequal. 
The temperature, like many of the other symptoms, is not constant, 
but it varies from 101° to 105° F. The pulse is accelerated at first, 
becoming slower by cerebral compression, and later again increasing. 
The respiration is irregular and jerky in inspiration, followed by a 
pause, and of a lengthened, sighing character in expiration. Hemi- 
plegia or paralysis of one or more extremities may occur, and when 
the third, fourth, or sixth nerve is involved strabismus follows. At 
last the power over the bladder and bowels is lost, the respiration is 
accelerated, the pulse rapid and compressible, and finally general pa- 
ralysis is followed by coma and death. 

Diagnosis. — This is, many times, difficult to determine, especially 
in children. The elimination of any other affection in the course of 
a purulent inflammation of the middle ear, the occurrence of con- 
stant fever, headache, and vomiting constitute the most important 

(143) 



144 EXTRADURAL ABSCESS. 

diagnostic points. Add to these the signs of injection of the retinal 
vessels and often neuritis, and the diagnosis is rendered quite certain. 

Prognosis. — Without operation, death. 

Treatment. — If cold is agreeable the ice-cap should be continu- 
ously applied, bromidia given for pain, and the bowels relaxed. If 
a specific infection is suspected, iodide of potassium is indicated. The 
great fatality warrants an early surgical operation, which is described 
below and in Chapter XV. 

Extradural Abscess. 

This is a localized accumulation of pus hemmed in by adhesions 
of the meninges to the internal table of the skull. It generally re- 
sults from a slow extension of the disease of the tympanic cavity 
through the thin partition of the bone separating the latter from the 
cranial cavity. 

Symptomatology. — There are generally some fever, intense pain 
over the temporal bone, and the symptoms of meningitis; exacerba- 
tions are followed by improvement after a sudden discharge occurs 
from the ear. The abscess may not be located in any part of the 
motor tract; so that no localizing symptoms appear. Frank S. Mil- 
bury details an instance of suppuration of the middle ear and mas- 
toid process eventuating in a subdural abscess with consequent press- 
ure on the left temporo-sphenoid lobe of the brain. There were 
facial paralysis of the left side, slight paralysis of the right arm and 
leg, impaired mentality, and amnesic aphasia. (The Laryngoscope, 
December, 1897.) The temperature rarely rises above 102° F. Ten- 
derness over the painful area is usually present. When the cerebellar 
fossa is invaded, giddiness and vomiting may be expected. 

Diagnosis. — This is obscured, as appears from what has been 
said, by the indefiniteness of the symptoms. The points in diagnosis 
are detailed above. 

Prognosis. — This is unfavorable if the abscess rupture internally, 
but if it breaks externally or is evacuated by operation recovery may 
take place. 

Treatment. — Operative treatment only is effective. It consists 
of laying bare the tympanic cavity by the Stacke method (see "Mas- 
toid Operations"), evacuating the pus-cavity, removing all granula- 
tions and dead bone, cleansing, disinfecting, and dressing with aristol 
or iodoform and sterilized gauze. If no pus is found and the cerebral 



CEREBRAL AND CEREBELLAR ABSCESS. 145 

pulsation is absent, as often happens in brain-abscess, the aspirator- 
needle may be used to explore the site of a suspected pus collection. 

Cerebral and Cerebellar Abscesses. 

These are the result of a chronic, rather than acute, suppuration 
of the middle ear. Over one-fourth of all cerebral abscesses follow 
this disease. Twice as many men as women are subject to brain- 
abscesses. They are generally located either in the temporal lobe or 
in the same side of the cerebellum as the aural disease (Bergmann). 
They may be deep-seated or superficial, single or multiple, in one or 
both sides of the cerebrum. Caries in the roof of the tympanum 
usually causes cerebral abscess, which covers the posterior surface of 
the pyramid, but caries in the mastoid process causes cerebellar ab- 
scess. The size of the pus-cavity varies from an eighth of an inch 
(three millimetres) to several inches (centimetres) in diameter. 

Symptomatology. — Bergmann classifies the symptoms of such 
abscesses as follow: 1. Those of suppuration: paroxysmal fever, 
chills, dullness, depression, loss of appetite, indigestion, rise of tem- 
perature in region of abscess, and tenderness on percussion. 2. 
Pressure symptoms: headache, dizziness, unconsciousness, delirium, 
twitching and paresis in extremities and facial muscles, strabismus, 
disturbance of vision and speech, slow pulse, sleepiness, Cheyne- 
Stokes respiration, eclamptic attacks, and intermissions. 3. Pus in 
the temporal lobe, with inability to speak certain words, is rare. In 
the cerebellum it produces dizziness and a staggering gait. 

The time-limits of brain-abscess are very variable. It may exist 
indefinitely without urgent symptoms. An old abscess contained 
within a connective-tissue capsule may remain innocuous until it 
ruptures outwardly, producing meningitis, or until encephalitis su- 
pervenes in its vicinity, or it may discharge into the ventricle. A 
fatal issue may result from metastatic abscesses. For example, the 
waiter has seen the whole anterior aspect of the thigh converted into 
an immense pus-reservoir. There is a marked predilection for the 
lungs. The end may be preceded by cerebral compression, great 
prostration, or paralysis of the respiratory or circulatory centres. 

Diagnosis. — This is sometimes impossible, for the symptoms are 
absent until the end approaches. When the health steadily declines 
without other assignable cause, coupled with otorrhcea, insomnia, con- 
stant temperature of about 99° F., localized pain in the same side of 



146 OPERATIONS FOR BRAIN-ABSCESSES. 

the head or in the occiput, we are safe, by the process of exclusion, 
in arriving at a diagnosis of this disease. 

Prognosis. — Without operative interference the termination is 
fatal, but the prognosis has been illuminated with the brilliant rec- 
ords of Macewen and Ivorner, 95 per cent, recovering from operations 
by the former and 60 per cent, of the cases compiled by the latter. 

Treatment. — Until a diagnosis can be made, there remains little 
to do except to direct our efforts toward improving the general health 
and relieving temporary symptoms. A surgical operation is the only 
curative measure. 

Operations for Brain-abscesses. 

Eeferring to the skull (Figs. 98 and 99) that the author has 
prepared to illustrate the various operations for trephining and for 
mastoid diseases, the surgical relations of the parts involved will ap- 
pear. The field of operation is prepared on the previous day by shav- 
ing, scrubbing with soap and water, and afterward with alcohol or 
ether, leaving a generous margin hairless (Fig. 113). Then the head 
is bandaged with sublimated gauze. The bowels are relaxed by a 
saline draught on the previous evening and evacuated by an enema 
on the morning of the operation. Nothing but beef-tea is allowed 
on the operating day. While ether is generally to be preferred in 
other operations, chloroform is allowable in this instance, since it 
causes a depression of the cerebral centres, while ether acts as an 
excitant. 

The point selected for the centre of the half-inch trephine is 
seven-eighths of an inch above the centre of the meatus (Fig. 98). 
Incisions at right angles to each other are usually made, intersecting 
each other at this point, although Horsley prefers a semicircular flap. 
The cut should penetrate to the bone, and all the soft tissues are 
raised (Fig. 93), preserving the periosteum, and retracted by the 
double hooks (Fig. 94). The trephine now having been used, if the 
opening is not capacious enough it can be enlarged without injuring 
the dura by an ingenious device of DeVilbiss, of Toledo, or with the 
chisel. The dura is opened in a valve-shaped flap by a circular in- 
cision one-eighth of an inch inside the bone-perforation, so as to 
permit of this remaining margin being sewed to the flap of the dura 
afterward if necessary. If there is no cerebral pulsation the abscess 
may be expected to be superficial, but even if pulsation is present 
there may be a deeply-seated pus-cavity. 



SINUS-PHLEBITIS AND SINUS-THKOMBOSIS. 117 

The aspirating-needle should now be inserted in the supposed 
direction of the abscess if no pus appear. Or a sharp bistoury may 
be cautiously introduced once or twice or even a third time in dif- 
ferent places. If pus escape the opening is enlarged, as complete 
evacuation as possible is effected, and the cavity is cleansed, disin- 
fected, and packed with iodoform gauze, or a rubber drainage-tube 
may be inserted. If no pus is found the dura is sutured; the bone 
button, having been preserved in sterilized warm water, is replaced; 
the periosteum stitched in situ, the soft parts brought together, and 
the skin-wound is closed with the finest catgut suture. Sterilized 
gauze, absorbent cotton, and a bandage complete the dressing. 

"When the abscess is located over the roof of the mastoid antrum, 
the latter is opened, and in most of these cases it is filled with either 
pus or a cholesteatoma. Enough of the roof of the antrum is chiseled 
away to allow of examination of the dura. If the latter is covered 
with granulations or if no pulsation is present, it should be entered. 
If no pus is found, a way is made leading to the roof of the middle 
ear (Krister), avoiding the facial nerve and semicircular canals by 
going above the former and external to the latter. An incision is 
then made in the middle portion of the temporal lobe. The after- 
treatment is described above. Knapp (Archives of Otology, April, 
1895) performs the tympano-mastoid cranial operation for otitic 
brain-abscess. 

Cerebellar abscesses may be reached by chiseling the mastoid 
process so as to penetrate the posterior fossa without opening the 
lateral sinus, or the trephine may be used so as to perforate the occi- 
put between the occipital and the lateral sinuses (Fig. 98, v). It 
should not be forgotten to always give a very guarded prognosis. 
Besides the causes of fatal termination already mentioned the end 
may be hastened by haemorrhage from the middle meningeal artery, 
gangrene of the brain, pyaemia, and prolapsus of the brain. Zaufal 
{Archives of Otology, April, 1895) first opens the posterior fossa, and 
if results are negative then the middle fossa, if the cranial cavity is 
to be opened after a mastoid operation. 

Sinus-phlebitis and Sinus-thkombosis. 

These complications result from caries or necrosis of the poste- 
rior tympanic wall in a considerable proportion of cases, but the 
lateral (sigmoid) sinus is the vessel most often affected. The supe- 
rior petrosal and cavernous sinuses and the internal jugular vein are 



148 TREATMENT OF SINUS-PHLEBITIS AND SINUS-THROMBOSIS. 

rarely involved, the latter in caries of the inferior tympanic wall. 
While the cause is generally an extension of the necrotic process of 
the bone to the walls of the sinus, phlebitis may also result from 
septic infection transmitted by the veins communicating with the 
sinus. We may have accompanying this condition cerebral abscess 
or meningitis. The preceding suppuration has generally, but not 
always, been of long duration. The attack is sudden and character- 
ized by pain in the occipital region and neck, chills, loss of appetite, 
and a temperature above 104° F., with remissions. The pulse is rapid, 
the skin dry, the tongue dry and coated, but consciousness may or 
may not be affected. Occasional symptoms are dizziness, stiffness of 
the muscles of the neck, optic neuritis, vomiting, delirium, con- 
vulsions, coma, and others suggestive of septicaemia. When the in- 
ternal jugular vein is affected, a dense cord, tender on pressure, may 
be distinguished along the anterior border of the sterno-mastoid mus- 
cle if the neck has not become too oedematous. If the cavernous sinus 
is involved the oedema may extend to the face, nose, and eyelids. 
The fatal termination, which often occurs in about three weeks, is 
most likely to result from pyaemic pneumonia. However, the dura- 
tion varies greatly from a few days to months. Eecovery cannot be 
expected without surgical interference. 

Treatment. — Stimulants, nourishing diet, and antipyretics are 
indicated until the operation is decided upon. The mastoid process 
should be opened (see "Mastoid Operations") and the sigmoid sinus 
laid bare. If it has not the natural dark-blue color or pulsation, but 
is hard, thickened, and inflamed, a thrombus is probably present. If 
a broken-down thrombus or pus is present, there will be fluctuation 
and absence of pulsation. The aspirating-needle should be inserted 
to ascertain the nature of the contents. If either condition mentioned 
is found, the sinus should be laid open longitudinally with a sharp 
bistoury, cleaned out with forceps and curette, washed with bichloride 
solution, 1 to 2000, and dressed with iodoform gauze. 

If the internal jugular vein is thrombosed, it should be ligated 
low enough in the neck to get below the thrombus. The upper seg- 
ment is brought out of the wound, the thrombus removed and the 
vein is treated as already indicated. This will prevent infection of 
the lungs if resorted to early enough. 



CHAPTER XIV. 
DISEASES OF THE MASTOID PROCESS. 

Pathology. — Primary acute inflammation of the mastoid process 
is a rare disease. Any affection of this part is nearly always conse- 
quent upon a middle-ear inflammation. The disease may he limited 
either to the lining membrane of the pneumatic spaces or to the peri- 
osteum of the cortex, or both membranes and the bone itself may be 
involved. In the acute form the latter condition is most likely to 
prevail, especially when it is consecutive to an acute middle-ear sup- 
puration. Unless the inflammatory process is speedily interritpted, 
necrosis of the hone may occur, with a growth of unhealthy granula- 
tions; the formation of a fistula, either externally through the cortex, 
presenting a post-aural abscess, or through the posterior wall of the 
bony meatus (Fig. 99), or internally, communicating with the cranial 
cavity through the lateral-sinus wall (Fig. 79) or through the roof of 
the tympanic cavity. In this manner the posterior or the middle 
fossa (Fig. 82) may be invaded by the purulent discharge, thus giving 
rise to meningitis, subdural abscess, sinus-thrombosis, pyaemia, or 
brain-abscess. M. D. Lederman reported a case of extension of mid- 
dle-ear and mastoid suppuration to the cranial cavity, in which "soft- 
ening of the lower portion of the right temporo-sphenoid lohe of the 
brain was found, accounting for paralysis of the arm and leg of the 
opposite side** {The Laryngoscope, July, 1896). Moos (Archives of 
Otology, July, 189-1) reported a case of "mastoid disease extending 
outward by way of the mastoid fissure, the continuation of the petro- 
squamous suture.'* 

In the more favorable cases the discharge contained within the 
antrum and cells may find exit through the middle ear and external 
canal, or, if pus form beneath the mastoid periosteum, the resulting 
post-aural abscess may rupture spontaneously. This often occurs 
when the pus has found its way from the antrum through a fistulous 
opening in the cortex: so that the mastoid antrum comes into direct 
communication with the external world. In 1881- the author treated 
such a case in a lady nearly 80 years old. The discharge had ceased 
and there was a fistulous opening, surrounded by the blackened, ex- 

(119) 



150 



DISEASES OF THE MASTOID PEOCESS. 



posed bone three-eighths of an inch (one centimetre) in diameter, 
leading into the tympanic cavity. The hearing for conversation was 
not lost, no inconvenience was suffered, and she did not wish the 
opening to be closed. The patient remained in excellent health when 
last seen, twelve years afterward. 

An occasional result of inflammation of the mastoid cells is a 




Fig. 82. — Interior of base of skull. LS lateral (sigmoid) sinus; U, 
parallel lines over the superior semicircular canal; 0, internal auditory 
meatus; X, opening by trephine for abscess over the middle ear. The 
cranial fossae and sinuses are shown. (Author's preparation.) 



proliferation of osseous tissue, which fills and obliterates the pneu- 
matic spaces, leaving the whole area a dense, ivory-like mass. I have 
encountered a few such processes in which no pneumatic cells could 



DISEASES OF THE MASTOID PEOCESS. 151 

be found, and the chisels were bent and chipped as though driven 
against stone (osteosclerosis). 

Etiology.; — Primary mastoiditis may occur as the result of trau- 
matism or exposure to cold. Generally mastoid disease is a complica- 
tion and is most prevalent during influenza epidemics. In the latter 
case, at least, it is probable that a bacterial infection occurs through 
the Eustachian tube from the respiratory passages, since it has been 
demonstrated that the diplococcus of pneumonia is present in the 
mastoid discharge (Scheibe). Frank Eumbold reported a. case of 
mastoiditis in April, 1898, in which he attributed the attack, in a 
patient suffering from diabetes, to carious teeth of the lower jaw. 
After a mastoid operation had been performed without marked relief 
the diseased teeth were extracted, after which the patient experienced 
freedom from pain and made a good recovery. 

It should be borne in mind that the relations of the antrum and 
middle ear, being connected by the aditus ad antrum, or passage from 
the tympanic attic to the antrum, are such that any fluid in the tym- 
panic cavity naturally gravitates into the mastoid antrum when the 
patient reclines upon his back. Indeed, the antrum is the drip-cup 
of the tympanum, and whenever there is considerable fluid in the 
middle ear it finds its way into the antrum. This does not of ne- 
cessity imply an inflammation of the pneumatic cells, but when micro- 
organisms — streptococci, etc. — are present the danger to the integrity 
of the lining membrane and delicate cellular structures is apparent. 

Symptomatology. — Acute mastoiditis is accompanied with pain, 
which, though slight and annoying at first, becomes violent and ex- 
hausting as the disease progresses. After a few days the tongue be- 
comes coated and the temperature elevated two or three degrees. If 
there is periostitis there are also tenderness, redness, and swelling over 
the mastoid region. Pain is sometimes referred to the temporal, the 
supra-orbital, or the occipital region. Fluctuation denotes either a 
subperiosteal abscess or a fistula. Great variations in temperature 
during the day should excite suspicion of sinus-thrombosis; but as 
descriptions of intracranial complications have already been given 
(Chapter XIII) they will not be repeated here. A most noticeable 
sign of mastoid periostitis and oedema of the overlying structures is 
a pronounced prominence of the auricle, which projects out promi- 
nently at a right angle to the side of the head. 

Pain is not always present in mastoid disease, especially after 
the acute stage has passed, and one must not expect to find the whole 



152 DISEASES OF THE MASTOID PEOCESS. 

group of symptoms present in every case. They are not constant. 
Great destruction may take place in the process without proportionate 
discernible manifestations. This demonstrates the insidious and dan- 
gerous character of the disease. If there is no ear discharge in acute 
mastoiditis of the cells, one may expect to find a bulging drum-head, 
and the postero-superior wall of the meatus may be found depressed. 

The inflammatory process may continue for several weeks with 
recurrences and remissions of the symptoms, but the closest watch 
must be kept in order that any impending invasion of the cranial 
cavity may be averted by prompt surgical interference. Pus may in- 
vade the middle fossa through the tympanic roof or antrum. If it 
break posteriorly from the middle ear or mastoid cells, it reaches 
either the lateral sinus or the posterior fossa.. If it advance ante- 
riorly from the middle ear, it may form a superficial abscess in the 
neck or a retropharyngeal abscess. It may break through the inferior 
surface of the mastoid process and form an abscess beneath the sterno- 
mastoid muscle (Fig. 11^1). If it find an outlet through the inferior 
surface of the petrous portion of the temporal bone, it may burrow 
beneath the deeper layer of muscles even to the thoracic cavity. When 
the cervical tissues become infiltrated in the region of the sterno- 
mastoid muscle, or an abscess of the neck forms, the head becomes 
more or less fixed, the face everted, and movements involving this 
muscle are restricted and painful. When a retropharyngeal abscess 
is present the jaw is fixed and cannot be moved or depressed suffi- 
ciently to examine the tongue or throat except with great pain (Plates 
IV and Y). 

Diagnosis. — In acute mastoiditis the symptoms enumerated are so 
prominent and characteristic that no difficulty presents itself in recog- 
nizing the condition, but in chronic suppuration of the mastoid cells, 
in the absence of a fistula, it is not so simple a task. Persistent dis- 
charge, notwithstanding the treatment, foul odor, bulging of the 
postero-superior wall of the canal, tenderness over this region, and 
impaired nutrition indicate a mastoid disease. 

Prognosis. — Uncomplicated acute mastoiditis, subject to early 
treatment, presents a favorable outlook. A large proportion of such 
cases will recover without an operation; but the treatment must be 
instituted promptly in order to prevent extensive destruction of the 
bone and intracranial complication. When the latter occurs the 
jorognosis is unfavorable without an operation; but surgical interfer- 
ence presents good chances of recovery if not delayed until the occur- 



TREATMENT OF DISEASES OF THE MASTOID PEOCESS. 153 

rence of septicaemia, brain-abscess, sinus-thrombosis and phlebitis, or 
meningitis. Yulpius (Archives of Otology, April, 1895) reports three 
cases of influenzal otitis, mastoiditis, and epidural suppuration cured 
by operations. 

Treatment. — If the patient is seen before perforation of the 
drum-head occurs, and signs of fluid in the middle ear are discovered, 
paracentesis should be performed at once, as described in treating of 
acute inflammation of the middle ear (page 77). The incision should 
be a long one, for its tendency is to close soon. A case to the point 
occurred while writing this. It became necessary to make an ex- 
tensive opening in the drum-head and to incise the bulging posterior 
wall of the meatus, under ether, although a few days earlier a minute 
perforation was enlarged under cocaine. The first incision had healed, 




Fig. 83. — The author's ice- 

the discharge ceased, and great pain and a sense of pressure ensued 
from the accumulated pus that was unable to escape. 

In acute inflammation the ice-bag '(Fig. 83) should be applied 
without delay, and kept continuously in place until either the in- 
flammation subsides or it becomes evident that an operation is im- 
perative. The crushed ice must be replenished as fast as it melts. 
One or two days may be long enough, but I have found it necessary 
at times to maintain constant cold for three or four consecutive days 
and nights. Sometimes an exacerbation occurs and the ice must be 
resorted to again. This plan succeeds in some very serious cases, but 
if pus has formed the ice may fail. For example: two children about 
6 years old presented acute mastoiditis on the same day. and ice was 
applied alike to both. In five days one was discharged cured and the 



154 TREATMENT OF DISEASES OF THE MASTOID PROCESS. 

other' developed a post-aural abscess, on opening which a fistula was 
found leading to the antrum. The ice-bag was powerless in the one 
ease to avert a mastoid operation, because destruction of osseous tis- 
sue had already taken place. 

Counter-irritation by mustard over the whole mastoid region, 
and along the course of the Eustachian tube when it is involved, 
often assists materially. It should be used nearly, but not quite, 
to the point of vesication, and then replaced by spirit of camphor on 
a flannel compress until the blush fades and the cutaneous irritation 
is again indicated. 

Leeches afford speedy relief during the acute, intense stage . of 
the inflammation. They should be applied over the mastoid process 
near the auricle. Detailed directions for applying leeches will be 
found in the treatment of acute inflammation of the middle ear 
(page 76). General antiphlogistic treatment and anodynes are fre- 
quently called for, with laxatives for the bowels, as mentioned under 
the same heading. 

If the application of the ice-bag is followed in a few days by 
subsidence of pain, fever, and the other symptoms, or if the cold is 
badly borne, it should be discontinued. If, in spite of all these 
antiphlogistic measures, the steady march of the destructive process 
is not stayed, an operation must not be too long delayed. A week 
or ten clays may give sufficient time for extensive infiltration and 
invasion of the more vital organs. Nevertheless, the writer has seen 
numerous instances in which very grave and alarming symptoms have 
yielded to this palliative method of treatment, — cases in which ex- 
cellent surgeons believed an operation to be unavoidable. 

But it is a matter of duty to emphasize the possibility of a sud- 
den fatal termination if the necessary operation is too long post- 
poned. Fatal results have followed such delays and refusals to allow 
operations, but I have never seen a fatal termination due to the 
operation itself. The disease is dangerous; the operation itself is not, 
in the hands of a competent operator. If the mastoid process con- 
tain necrotic tissue, the operation affords immediate relief. It gives 
free exit to the pent-up discharges and removes a threatening cause 
of disaster. 

Any well-informed surgeon, after sufficient practice on the ca- 
daver, can perform the operation with safety and success if he follow 
closely the rules laid down; but in order to have well at command 
all the surgical relations of the parts concerned, the operation ought 



INDICATIONS FOE OPERATING ON MASTOID PROCESS. 15-3 

to be previously studied and performed numerous times on the ca- 
daver. To illustrate: out of seventeen mastoid operations the author 
has made in one month, twelve were on cadavers and five only on 
patients. 

M. D. Lederman advises, as an abortive measure, incision through 
the posterior fold of the drum-head, extending through Shrapnelhs 
membrane and into the superior wall of the meatus, so as to produce 
free blood-letting. (The Laryngoscope, January, 1898.) 

Wilde's incision, at least, should be made as soon as it becomes 
evident, by the presence of a fluctuating swelling back of the ear, 
that pus is present. Any one can do this with a sharp, strong bis- 
toury (Fig. 84:). The cut is made as nearly as possible in the line 
of the incision that may be required later for the mastoid operation, 
— about three-eighths of an inch (one centimetre) posterior to the 
insertion of the auricle and parallel with it (Fig. 105). The incision 
is carried down to the bone, the pus evacuated, and a fistula searched 
for with a strong probe. If none is present, and it is apparent 



Fig. 84. — Buck's mastoid knife. 

that the abscess is subperiosteal, and no superficial caries of the bone 
needs curetting, the cavity is treated antiseptically, as will appear 
later, until pus formation ceases. Then it is allowed to close. 

Indications and Peepaeations foe Mastoid Opeeations. 

Indications for Operating.— The following six rules, by which 
the perplexing question of when to operate is decided, were presented 
by the writer in a paper before the first Pan-American Medical Con- 
gress, and received the approval of the aural surgeons present, in- 
cluding Professor Politzer, with unanimity of opinion: — 

The mastoid process should be opened 

1. When there is acute inflammation of the bone that resists 
palliative treatment. 

2. When repeated swellings and abscesses occur. 

3. When there is a bulging of the posterior and superior wall 
of the meatus, with suppuration of the middle ear. 

4. When there is a fistula. 



156 



PREPARATION OF THE PATIENT POP AN OPERATION". 



5. When there are severe pains in the same side of the head as 
the diseased ear and they resist all other treatment. 

6. When a foul otorrhcea cannot be cured by any other means. 
These rules may be termed conservative, and whatever deviation 

we may indulge in ought to be at once favorable to the operation 
and the welfare of the patient. Too great temporizing favors sinus- 
thrombosis, septicaemia, brain-abscess, and meningitis. 

There are a few points in this connection worth mentioning, for 
they are closely related to a successful issue. Excellent illumination 
is had by the use of light reflected from a mirror on the operator's 
forehead, after the cortex is opened (Fig. 4). This affords a decided 
advantage over window-light. It is more intense, especially from the 
sixty-candle-power incandescent gas-burner (Fig. 5); it can be thrown 




Fig. 85. — The Nevius electric head-lamp. 



into the opening of the bone in every direction, and there are no 
shadows to obscure the field. The Nevius electric head-light (Fig. 
85) affords an ideal illumination for mastoid operations. It is at- 
tached to the head-band by a ball-and-socket joint, and it gives a 
very brilliant light, exceeding a 16-candle-power lamp. It is op- 
erated by connecting it by a plug to an incandescent-electric-lamp 
fixture. I have used this illuminator in mastoid operations with the 
utmost satisfaction. 

Preparation of the Patient. — The day preceding the operation 
the patient's mastoid region, together with an area of three inches 
in extent above and behind the auricle, is shaved and washed with 
soap and warm water, then with ether, and finally with very warm 
bichloride solution (hydrargyrum bichloride), 1 to 1000. The meatus 



PREPARATIONS FOR OPERATIONS. 



15' 



is syringed with the latter solution. The parts are then dressed with 
sublimated gauze and a bandage. The bowels are relaxed the same 
evening, and beef-tea only is allowed on the day of the operation. 



Fig. 86.- — A strong scalpel. 

Ether is preferable to chloroform on account of its greater safety. 
Only so much as is absolutely necessary to procure freedom from pain, 
movement, and shock is employed, in order to avoid a subsequent 
bronchitis or pneumonia. 




Fig. 87. — The author's mastoid chisel. Actual width. 

The patient's clothing is removed from his shoulders and a 
blanket, covered with a rubber sheet, is substituted, so as to have 
the clothes clean when he is returned to bed. The hair, especially in 
the case of females, need not be entirely sacrificed (Fig. 113), as is 



siiiigggigiiiMii 




^^^^^^22SK3«2ES ww;TOK ''«i 



amillli 



Fig. 88. — The author's long mastoid gouges. Actual width. 

often done, but it is preserved in a cleanly condition by enveloping 
it in a sublimated cap or towel. 

The operator and assistants prepare by rolling the sleeves above 
the elbows and vigorously scrubbing their forearms, hands, and nails 



158 



INSTRUMENTS KEQUIEED FOR MASTOID OPERATIONS. 



with brush, warm water, and soap, and lastly with alcohol. Kubber 
aprons and operating-gowns complete the surgeon's toilet. A table 
forty-two inches high is preferred by the writer in order to escape 




Fig. 89.— Lead-filled mallet. 



the necessity of a wearying, stooping position during the operation. 

The patient's head rests on a small rubber drainage-cushion (Fig. 95). 

The instruments, a quarter of an hour before they are needed, 

are boiled for five minutes in a 1-per-cent. solution of bicarbonate 




Fig. 90. — The author's set of curettes. 

of sodium, which does not corrode, and then they are placed in warm, 
sterilized water. The scalpels are simply immersed in boiling water 
a moment. For many years the writer used a 5-per-cent. carbolic- 
acid solution for the instruments, instead of boiling, but a serious 




Fig. 91. — The author's mastoid guide. 



objection to this was that the operator's fingers were benumbed by 
the acid, for the instruments were kept immersed in the solution 
during the operation. 

The instruments required are a couple of strong, sharp scalpels 



INSTRUMENTS REQUIRED EOR MASTOID OPERATIOXS. 159 

(Fig. SG), four artery-forceps, a periosteum elevator, self-retaining 
retractors, a strong chisel (Fig. 87), three sizes of long gouges (Fig. 
88), a metal mallet (Fig. 89), several sizes of curettes (Fig. 90), strong 
probes and forceps, a mastoid guide (Fig. 91), tongue-forceps (Fig. 
92), and a syringe (Fig. 33), with hot water. 




Fig. 92. — Mathieu's tongue-holding - forceps. 

The Periosteum Elevator, Retractor, and Curette. 

This hoe-shaped device (Fig. 93) overcomes a serious objection 
to the misnamed periosteotomes we have formerly used. Indeed, 
these instruments should not be "tomes" at all. They should not cut 
the membrane, but should lift it from the bone in continuity, so as 
to carefully preserve its integrity. 

The old periosteotomes put the operator at a disadvantage by 
necessitating an unnatural play of his muscles. With a pushing 
motion one has not perfect control of the movements of the instru- 
ment and it is likely to slip and cut where it is not desirable to wound. 
In the use of this kind of a lifter the motion is one of drawing or 




Fig. 93. — The author's periosteum elevator. 

pulling toward one's self; so that the muscles brought into play are, 
together with the instrument, under easy control, — on the same prin- 
ciple as the farmer's use of his hoe, after which it is patterned. 

As the separator serves the purpose not only of detaching the 
periosteum, but of retracting the loosened tissues, or of curetting 
necrosed bone, it may be said to constitute three instruments in one. 



160 INSTRUMENTS REQUIRED FOR MASTOID OPERATIONS. 

The self-retaining retractors (Fig. 94) take the place of an as- 
sistant in keeping the soft tissues out of the way of the operator and 
in controlling the hemorrhage during mastoid and other operations 
of like magnitude. The retractors consist of two shafts, each armed 
with a series of hooks that can be brought together and interlocked 
for insertion into the incision, when they can be separated and fixed 
at any desirable point up to two inches apart. After they have been 
drawn apart as far as may be required, the thumb-screw on the fixa- 
tion-bar next to the hooks should be screwed down firmly into the 
bar, the handles should be pressed a little together until the tissues 
are well stretched as the distal ends of the retractors separate, then 
the thumb-nut on the thread-bar should be turned down against the 
movable handle. 

If the instrument is properly adjusted the tissues cannot slip out 



Fig. 94. — The author's self-retaining retractors. 

of its jaws, and their pressure on the stretched lips of the wound 
reduces the haemorrhage to a minimum. In some operations these 
hooks have proved more effective than five artery-forceps. 

The following arrangement renders these retractors equally useful 
in the smallest and the largest mastoid operations: The terminal half 
of the shaft of hooks can be slipped out of the main half, leaving 
the retractors only an inch long. Eeplacing the adjustable series of 
hooks makes them two inches long, and by drawing these adjustable 
hooks outward one-half inch one can lengthen the hooks to two and 
one-half inches. This has the effect, when the instrument is in 
position in a large wound, of making an opening two inches to three 
and one-half inches wide by three or more inches long, through which 
to work. However, the opening can be made as small as one wishes, 
and the capacity of the instrument is far beyond what we usually re- 
quire in operations on the skull; but the writer has had it made so 



INSTRUMENTS REQUIRED EOR MASTOID OPERATIONS. 161 

as to be of service in other and more extensive operations, since its 
size in no way impairs its efficiency in mastoid cases. The handles 
are constructed to take up as little room as possible. 

When the adjustable parts of the hooks are removed for small 
operations the openings in the permanent hook-shafts, into which 
the adjustable hooks fit, may be securely sealed by a bit of beeswax 
to prevent the entrance of blood, etc. After being used, this wax 
will run out on the application of a little heat. A drop of oil should 
then be put in the same openings to prevent corrosion or sticking of 
the adjustable shanks. 

The straight-edged chisel is employed to open the firm cortex, 
but after the antrum or cells are reached the writers long gouges are 
better adapted to the work (Fig. 88). The length of the shafts allows 
the operators hand to be sufficiently removed from the cavity to give 
an unobstructed field of vision. 

As we cannot know the extent of the pathological process before 
entering the bone, it does not appear to be advisable to decide in ad- 
vance upon any special method of procedure save one: remove all 
dead and diseased tissue. "Whatever method does this is best. Stackers 
and Bergmanms operations have the advantage of affording the great- 
est accessibility to the tympanum; so that if it is necessary to remove 
necrosed ossicles or diseased tympanic tissue it can be done with greater 
facility and thoroughness. 



CHAPTER XV. 

THE MASTOID OPERATIONS. 

For our purpose it is most convenient and practical to treat of 
mastoid operations under three headings: (1) the Schwartze mastoid 
operation; (2) the radical tympano-mastoid operation; (3) the modi- 
fied operation. 

The Schwartze operation is the one most commonly performed, 
and is adapted for primary mastoid abscess, or that condition in which 
it is necessary to penetrate the bone without entering the tympanic 
cavity. 

The radical operation, devised by Stacke, is much more exten- 
sive and complicated, and is intended to open not only the antrum, 
but to expose the whole tympanic cavity and to remove one or more 
of the ossicles and any diseased tissue that may be found in the mid- 
dle ear. 

The modified operation is a convenient combination of the best 
principles governing the other two, more thorough than the first, and 
less menacing to important structures than the second. 

The Schwartze Mastoid Operation. 

All preparations having been made as already detailed (Figs. 95 
and 96), the ear cleansed, etc., the auricle is bent forward and the 
incision is made, beginning at the apex of the mastoid and extending 
upward and forward until within three-eighths of an inch (one centi- 
metre) of the auricular attachment; then it is carried parallel to the 
auricle to a level with its superior attachment. The incision should be 
made from below upward, for if made in a downward direction it is 
possible for the knife to slip off from the rounding surface of the mas- 
toid tip and plunge into the soft tissues of the neck, for one naturally 
bears hard upon the knife to cut to the bone. The posterior auricular 
artery or its anterior branch will have been severed and is caught up 
with the small artery-forceps and twisted. The forceps, can be left 
holding it, instead of stopping to ligate. 

The bleeding may be considerable for a few minutes, and if a 

(162) 



THE SCHAVABTZE MASTOID OPEEATIOX. 



163 



.pus-cavity is opened the contents usually gusli out with considerable 
force. The haemorrhage is dried rapidly with small pieces of moist 
sterilized gauze, the assistant consuming as little time as possible. 
If necessary, several small artery-forceps can be used to arrest the 
venous now, and they can be left in situ when the retractors are 




Fig. do. — A mastoid operat 



applied. The periosteal elevator (Fig. 93) is now used to separate 
the periosteum backward far enough to expose all the surface cov- 
ering the cellular part of the bone, and forward to the posterior mar- 
gin of the external meatus. The periosteum should be kept intact 
and carefully preserved. The self-retaining retractors (Fig. 94) are 
then inserted into the wound, the teeth being interlocked and resting 



16 J: THE SCHWARTZE MASTOID OPERATION. 

on the denuded bone. They are then separated as far as possible 
and fastened as previously described. In short incisions, as in chil- 
dren, the additional hooks are not needed. The haemorrhage now 
l^ractically ceases from the soft tissues because of the pressure and 
stretching by the hooks. If a fistula in the bone is found, it is en- 
larged; if there is none, and the antrum is sought, the bone is 
opened on a level with the superior border of the external meatus 
and three-eighths of an inch (one centimetre) back of its posterior 
wall (Figs. 97, 98, and 99). 

The mallet and straight-edged chisels are used to remove the 








Fig. 96. — Operating-room and accessories. 

cortex in preference to the trephine or drill. The broad chisel is best 
here. The strokes of the mallet must always be light enough to run 
no risk of forcing the chisel through softened bone into the vital 
parts. 

The general direction of the cone-shaped mass of bone to be 
removed is inward, forward, and a little upward (Fig. 97); but one 
must always bear in mind that these are relative terms, for we speak 
as if the patient were in an upright, instead of a supine position. A 
good rule is to keep close to the meatus, follow its direction, and 
keep above the horizontal plane of its axis if the antrum is to be 
opened (Fig. 100) and the facial nerve avoided. 



THE SCHWARTZE MASTOID OPERATION" 



165 



As soon as the cortex is removed the forehead-mirror or electric 
lamp (Figs. 4 and 85) and brilliant illumination should be used (Fig. 
5). If dead bone is reached there is little or no difficulty in distin- 
guishing it from the healthy. It is softer, darker, crumbling, and 
is often filled with dark, fungus-like granulations as well as pus. It 
breaks down readily under the curette and should be entirely re- 
moved until nothing but healthy tissue is to be seen. 

The opening in the cortex should be made spacious enough to 



5 4 




Fig. 97. — Horizontal section through right temporal bone, cut two 
millimetres above the centre of the external canal. 0, opening in mastoid 
leading to antrum; the heavily-dotted lines indicate the depth to which 
the opening penetrated in the upper section of this bone; small arrow in- 
dicates the relative position of the spina ; 22, wedge between opening in 
mastoid and external meatus; M, mastoid; 23, dotted lines indicating 
how osteosclerosis may increase the depth to which it is necessary to pene- 
trate; C, external canal; *, large cell in direct communication with the 
floor of the antrum above; LS, lateral sinus; z, posterior semicircular 
canal; A, facial nerve; x, horizontal semicircular canal; 2, vestibule; 1, 
internal canal; 3, cochlea; 4, fenestra ovalis; 10, Eustachian canal; MT, 
membrana tympani. (After C. E. Holmes.) 



allow of easy inspection of all the interior of the process. In the 
adult the oval aperture should be about one-half by three-fourths of 
an inch in diameter or ten bv twelve or fifteen millimetres, with the 



166 



THE SCHWARTZE MASTOID OPERATION 



long axis in the vertical. The surgeon should be satisfied with noth- 
ing but thoroughness of detail. If the carious bone extend to the 
dura or lateral (sigmoid) sinus it is removed thus far, exercising great 
caution not to injure either, and, although it has often been neces- 
sary to expose both, we have never seen any ill results follow. If 
the sinus should be accidentally opened, the hemorrhage will be 
profuse and will probably necessitate tamponing the cavity with iodo- 




Fig. 98. — Side-view of a skull, showing (Hi) opening in mastoid process 
for Schwartze operation. The wavering black line just above 1 is the course 
of the facial nerve exposed; above and at the left of this is seen the tym- 
panic cavity; ii, opening by trephine to explore the roof of the middle ear; 
Hi lie over the course of the lateral sinus; iv, Heed's base-line; f, trephined 
opening for cerebellar abscess. (Author's preparation.) 

form gauze and postponing further operative procedure for a fort- 
night, unless sufficient pressure can be exerted to suppress the bleed- 



The variation in the distances between the external canal and 
the lateral (sigmoid) sinus is shown in the same individual on the 
opposite sides of a skull in my possession (Figs. 82, 101, and 102). 
The surgical relations and close proximity of the sigmoid sinus, the 



THE SCHWARTZE MASTOID OPERATION. 



167 



tacial nerve, and the semicircular canals are plainly visible in Figs. 
97, 101, and 103 (LS, X, etc.). 

In many cases this operation suffices to effect a cure and it is 
not necessary to proceed farther. All projecting spicule of bone are 
removed, rough corners rounded off, the wound is syringed with 
quite warm bichloride solution, 1 to 1000, then dried and sprinkled 
with aristol (Fig. 34) or iodoform powder (Fig. 67). The upper sec- 
tion of the wound is stitched to a level with the upper border of 




lig. 99. — Schwartze operation. View of skull from below, showing 
tympanic cavity, looking from below upward and inward. The antero- 
inferior wall of the osseous meatus is removed, i, postero-superior wall of 
the meatus; at the right of i is an opening into the mastoid cells; ii, 
opening above meatus for cerebral abscess; Hi, Schwartze opening into 
antrum; v, opening for cerebellar abscess; 6, exit of facial nerve (black 
line running downward) ; 7, stirrup in foramen ovale. The dark space 
just above the stirrup shows the opened Fallopian canal. (Author's prep- 
aration.) 



the bone-opening only. The cavity is packed very lightly with iodo- 
form gauze, covered thickly with absorbent cotton, and the dressing 
is completed with a net or crinoline bandage. These bandages are 



168 



THE SCHWARTZE MASTOID OPERATION. 



not to be applied very firmly, since the sizing they contain, being 
moistened before they are applied, dries and contracts, setting some- 
what like a plaster-of-Paris bandage. Later, a rubber adhesive plaster 




Fig. 100. — Opening of the antrum. W W and T Y, horizontal and 
perpendicular planes of the skull; 0, opening in mastoid leading to antrum; 
OA, antrum; LS, lateral sinus; M, mastoid process; 22, posterior wall of 
external meatus; 15, styloid process; MT, membrana tympani; 14, glenoid 
cavity; 28, Glaserian fissure; 17, zygomatic process; 12 and 13, outlines 
of hammer and anvil and location of attic; 16, spina supra meatus; 
'*, dotted lines showing position of antrum; E, linea temporalis. (After 
C. R. Holmes.) 



THE SCHWARTZE MASTOID OPERATION. 



169 




O^lfiZ 



2\« 3\0 "i 



Fig. 101. — Horizontal section through right temporal bone, showing 
distance between lateral sinus and external canal. Cut begins below centre 
of external canal, passing obliquely upward and inward. LS, lateral sinus; 
M, mastoid; N, facial nerve; TC, tympanic cavity; 2, vestibule; MT, 
membrana tympani; C, external canal; small arrow indicates the point 
where a perpendicular line from the spina supra meatus would touch. 
(After C. R. Holmes.) 




Fig. 102. — Horizontal section through right temporal bone, cut near 
centre of external meatus, showing how close the lateral sinus may come 
to the external canal in some cases, a, internal carotid artery; T 7 , internal 
jugular vein. For explanation of other letters see Fig. 97. (After C. R. 
Holmes.) 



170 



THE SCHWARTZE MASTOID OPERATION, 



can be substituted for the bandage (Fig. 104). The wound is kept 
sufficiently open to permit inspection and treatment until the cavity 
fills with healthy cicatricial tissue. 

The patient is now put to bed. In case the temperature was 
high before the operation it usually falls, but it may remain near 
100° F. for a few days. The dressing is not disturbed for four or five 
days unless considerable haemorrhage, discharge, odor, pain, or fever 
should call for it. Too frequent dressings and forcible irrigations 
retard new tissue formation, while too infrequent dressings favor 
decomposition, septic infection, and exuberant granulations. Even 



-ZS 




Fig. 103.- — Perpendicular section through the right temporal bone, be- 
ginning at line B B, behind opening O in mastoid (Fig. 100), and directed 
inward and forward, cutting Eustachian tube in its long axis. N, dotted 
lines show the course of the facial and chorda- tympani nerves; M, mas- 
toid; Ck, chorda-tympani nerve; MT, membrana tympani; a, canal for 
internal carotid; 10, Eustachian tube; 9, processus cochliariformis; At, 
attic; 7 and 8. showing defects in the bone covering attic and antrum; 
OA, opening into antrum (Fig. 100); LS, lateral sinus;*, antrum; O, 
dotted lines indicating funnel-shaped opening (Fig. 100). (After C. R. 
Holmes.) 



in this operation the author often connects the middle ear with the 
mastoid opening so as to permit a current of water to pass into one 
and out of the other for the sake of absolute cleanliness. 



THE SCHWAETZE MASTOID OPEEATIOX 



171 




Fig. 104. — Adhesive-plaster dressing for mastoid wound. (Author's case.) 




Fig. 105. — Line of incision healed two months after a Schwartze operation. 

(Author's case.) 



173 



THE KADICAL TYMPANO-MASTOID OPERATION 



The duration of this operation, from the first incision to the 
completion of the operation and insufflation of the powder, has varied 
in my practice from fifteen to thirty-five minutes. With good as- 
sistants one can acquire dexterity in operating without incurring any 
risks, and the patients make a better recovery than when narcosis is 
protracted. The length of time required for complete recovery varies 
greatly. We have had patients leave the hospital in a few days or a 
week and have found them cured at the expiration of the fourth 
week, while others, for various reasons, extend over three or four 
months. Six or eight weeks would be a fair average time to give 




Fig. 10G.— The Stacke operation completed. (After C. R. Holmes.) 

as necessary for a cure, and patients should be informed that it may 
require longer (Fig. 105). 



The Radical Tympanomastoid Operation (Stacke). 
The first incision is the same as in the simple operation, except 
that it is carried above the insertion of the auricle and then forward 
as far as a point directly superior to the anterior wall of the meatus 
(Fig. 106). After the periosteum is raised to the margin of the 
meatus the periosteal end of the mastoid guide (Fig. 91) is inserted 
between the posterior wall of the osseous canal and its periosteal 



THE RADICAL TYMPANOMASTOID OPERATION. 



173 




Fig-. 107. — ^ide of skull, showing' Stacke operation. The postero- 
superior wall of the meatus is removed. The antrum is seen below 8 and 
the oval window at the right of 9. Below the oval foramen is seen the 
round window, and the dark spot above and to the right of the 9 is an 
opening into the external semicircular canal. The projecting ridge between 
this and the oval window is the Fallopian, or facial, canal. 12, point for 
trephining to open the lateral sinus. (Author's preparation.) 



174 



THE RADICAL TYMPANOMASTOID OPERATION. 



lining, and the latter is raised as far as the membrana tympani. One 
can tell when the middle ear is reached, for at that instant resistance 
ceases. The instrument is carried no farther inward, but is moved 
carefully around the whole circumference of the canal, separating 
the membranous lining and preserving its integrity. 

The integument is now drawn out of the canal like a severed 
glove-finger and reflected forward with the auricle so as to expose the 
bony canal and drum-head. The latter is now detached. The poste- 
rior canal-wall is chiseled away, backward into the antrum and in- 
ward as far as the tympanic attic (Fig. 107), removing the wedge- 




Fig. 108. — Vertical section through the ear. I, wedge-shaped portion 
of hone forming outer boundary of the tympanic attic; dotted line shows 
the section removed in the Stacke operation; 5, dotted line shows course 
of facial nerve; the bright spot in the dark area between 4 and 5 is the 
end of the probe, seen through the aditus ad antrum, resting in the antrum; 
6, remnant of the drum-head. (Author's preparation.) 



shaped portion of bone constituting the outer boundary of the attic 
(Fig. 108, No. 4), until a bent probe, in contact with the attic-roof 
and drawn outward, meets no resistance. The whole inner wall of 
the tympanum is now exposed to view, and this cavity, the antrum, 
and the meatus are converted into one cavity. The surgical relations 




Fig. 109. — Section of the temporal bone (actual size) through the mas- 
toid cells, Fallopian canal, and middle ear, severing the incudo-stapedial articu- 
lation. 1, membrana tympani. 2, tip of the mallet-handle. 3. chorda-tympani 
nerve, at the left of which is seen the canal for the tensor-tympani muscle. 
4, head of the mallet. 5, articulating surface of anvil for the mallet. 6, 
aditus ad antrum, connecting the tympanic attic with the mastoid antrum. 
7, usual location of the mastoid antrum; but in this anomalous specimen 
there are only capacious pneumatic spaces, instead of a large cavity. 8, 
Fallopian canal for the facial nerve. 9, long crus of the anvil for articula- 
tion with the stirrup. 10, large cavity, or antrum, in the tip of the mastoid 
process, another anomalous condition, with a thin shell of bone forming the 
cortex: between this antrum and 7, where the antrum should be normally. 
is a series of large cells connecting the two portions. 11, articulating surface 
of the stirrup for the anvil. 







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Fig. 110. — Section of the temporal bone (natural size) through the mid- 
dle ear, Fallopian canal, mastoid antrum, and cells, showing dense bone be- 
tween the antrum and cells, with no communication between them. 1, drum- 
head. 2, tip of the mallet-handle. 3, anvil, showing the long crus at the 
right for articulation with the stirrup, and the short process at the left which 
serves the purpose of an anchor to the bone. 4, head of the mallet. 5, tensor- 
tympani muscle and tendon. 6, dense bone where pneumatic spaces are usu- 
ally found. 7, pneumatic cells in the tip of the mastoid process. 8, Fallopian 
canal, for the facial nerve. 9, the stirrup. At the right of 9 and at the left 
of the anvil is the aditus ad antrum, connecting the tympanum with the 
antrum. 



THE RADICAL TYMPANOMASTOID OPERATION. 



175 



of these parts are clearly shown in Figs. 109 and 110. The anvil is 
detached from its articulation with the stirrup (Fig. 59) and removed 
with the pincette (Fig. 58), care being taken not to dislocate the 
stirrup and thus open the vestibule. The drum-head is removed in 
its entirety, together with the mallet. This is a simple maneuver, 
under the present conditions. All carious or necrotic tissue, granu- 
lations, or cholesteatomata are curetted away (Fig. 80). 

When the membranous canal is returned to its place it is incised 
along the median line of the posterior wall, longitudinally, up to the 




***■*-.■■•. . • 



Fig. 111. — Horizontal section of temporal bone, cut near floor of ex- 
ternal meatus, a, canal for internal carotid; TC, tympanic cavity; MT, 
membrana tympani; T, bulbus of internal jugular vein; N, facial nerve; 
LS, lateral sinus; J/, mastoid. (After C. E. Holmes.) 



concha, where an incision at right angles to the first is made through 
the posterior half of its circumference. The two resulting flaps are 
packed, — the one upward and backward and the lower downward and 
backward into the mastoid cavity. This gives access to one large 
cavity for after-treatment through the meatus. 

In this operation we have not only the lateral (sigmoid) sinus and 
dura to avoid, but the facial nerve and semicircular canals. To 



176 



THE RADICAL TYMPANOMASTOID OPERATION. 



escape wounding the facial nerve, as soon as we arrive in its vicinity 
the mastoid guide (Fig. 91) is inserted into the attic, and the nar- 
row toe of the foot-plate is passed through the aditus ad antrum and 
toward the antrum. The long handle is brought forward and down- 
ward over the cheek so that the end of the handle lies in a direct 
line with the lower border of the upper teeth or lip. Then the foot- 




Fig. 112.— Six weeks after Stacke operation. 1, point to apply electric current 

to affect superior branches of the facial nerve; 2, to affect inferior 

branches in treating facial paresis or paralysis. (Author's case.) 



plate falls over the Fallopian canal containing the nerve, and the 
chisel will strike the guide before it can reach the nerve. An as- 
sistant is instructed to hold the guide scrupulously in place and to 
give warning instantly when it is touched. The facial canal is some- 
times deficient or destroyed, leaving the nerve exposed. 



THE EADICAL TYMPANOMASTOID OPERATION 



177 



It is of the greatest importance to avoid injury of the facial 
nerve, as it produces a shocking deformity of the face (Fig. 75). I 
have seen facial paralysis produced, in my opinion, by packing the 
wound-cavity too firmly with the gauze, producing pressure on the 
exposed nerve. 

An anomalous position of the facial nerve renders it liable to 
injury if one chisels near the floor of the external canal. In using 




Fig. 113. — Appearance two weeks after the modified operation. Healed 
five weeks after the operation. (Author's case.) 



the middle-ear curette one should not forget that the tympanic walls 
are sometimes as thin as an egg-shell (Figs. 103 and 111). The in- 
ternal carotid artery and the internal jugular vein are sometimes very 
imperfectly protected and liable to be penetrated. As one proceeds 
upward and backward the external and posterior semicircular canals 
must be avoided. 

The radical, or Stacke, operation consumes more time than the 
simple, or Schwartze, operation. The time varies with different op- 



178 



THE MODIFIED MASTOID OPERATION. 



erators from one to two hours. Longer time is required for healing 
also on account of the greater extent of wound-surface. Fig. 112 
shows progress six weeks after the Stacke operation. 

The Modified Mastoid Operation. 

In this operation the incision is the same as in the radical one 
(Fig. 106). The writer does not dissect out the whole integumentary 
canal, but separates only its postero-superior half from the bony wall 




Fig. 114. — Post-mortem section of mastoid process. T, tip of process; 
2, fistula below T leading into mastoid cells; 3, opening made by trephine, 
probe resting in antrum; 4, cotton in. external meatus. (Author's speci- 
men.) 



and then depresses it sufficiently to give easy access to the tympanic 
cavity. By this means one-half of the soft meatus is left undisturbed 
and the integrity of the integumentary canal is preserved. This 
method leaves a less extensive wound to heal, and it has afforded the 
most satisfactory results. The collapse of the canal can be pre- 



THE MODIFIED MASTOID OPERATION 



179 



vented by lightly packing the mastoid wound and by packing the 
canal or inserting a firm-rubber tube. In other respects this method, 
which the author has preferred for several years, corresponds to the 
Stacke operation. 

It is safer not to close the wound entirely until it has healed 
from tlie bottom. When the interior has filled with firm cicatricial 
tissue up to the surface of the bone-opening it is safe to allow it to 
close. We have had good results after closing the wound completely 
at the end of the operation, but it is certainly not so safe a plan. 




Fig. 115. — Appearance three Aveeks after a modified Stacke and an 
operation for a neck-abscess. The latter is healed and the former kept open 
until the wound-cavity filled with healthy tissue. Patient discharged cured 
fifty-five days after operation. 



The best dressing is one of dithymol diiodide (aristol) sprinkled 
over the wound-surfaces, covering them entirely. Then iodoform 
gauze should be placed lightly in that part of the wound chosen to 
remain open. It should not be packed down to the bottom of the 
wound so firmly as to crowd any discharge inward, but it should fill 



180 



THE MODIFIED MASTOID OPERATION. 



the cavity and keep the cutaneous tissues from closing over the su- 
perficial opening in the bone. Dithymol diiodide has two excellent 
qualities: it is the best cicatrizant we possess, and it has the addi- 
tional advantage of being to some extent an anaesthetic. While iodo- 
form is irritant and toxic and boric acid sometimes produces pain, 
dithymol diiodide soothes without any ill effects. 




Fig. 116. — Abscess of the mastoid process extending over ten weeks, re- 
sulting in an enormous abscess of the neck, reaching nearly to the 
thoracic cavity. Cured by an operation. (Author's case.) 



After stitching that part of the wound to be closed, and dress- 
ing the open mouth for drainage, the whole is covered with sterilized 
gauze, absorbent cotton, and a net bandage. This bandage is made of 
the common white mosquito-cloth, which, as used in the Northern 
States, is sized with a preparation of glue. The roll of bandage is 
dipped in sterilized water just before applying, until it is wet through. 
Then the water is squeezed out and the bandage is applied as usual. 



ABSCESS OF THE XECK. 



1S1 



When it dries, the layers adhere tog-ether firmly, so as to retain their 
position for many days in succession without any attention. 

This operation requires more time than Sehwartze's and less than 
Stackers, both to perform and for healing. Fig. 113 shows progress 
two weeks after the modified Staeke operation. Three weeks after 
the operation taste was suddenly lost, hut returned again. The ex- 




Fig. Hi. — The same as Fig. 116, showing the outline of the swelling. 

uberant granulations seen on the right border of the wound were re- 
pressed with silver-nitrate stick. 



Abscess of Xeck ebcoi Middle-Ear axd Mastoid 
Sutpcbatiox. 

This is an occasional complication that requires operative in- 
terference. It arises from the purulent process penetrating the bone 
and burrowing beneath the superficial or deep layer of muscles. If 



182 ABSCESS OF THE NECK. 

it break through the inferior wall of the tympanic cavity, the 
pus-channel may extend along underneath the deep layer of mus- 
cles even to the thoracic cavity. If it rupture through the anterior 
wall of the middle ear, a retropharyngeal abscess or a superficial cer- 
vical abscess may develop. When the pus breaks through the inferior 
surface of the mastoid process (Fig. 114), it burrows under the sterno- 
mastoid muscle and forms a swelling on the side of the neck. At first 
the tumor is small, is generally located directly below the lobule of the 
auricle, is hard to the touch, and may give so little evidence of its 
presence that it may be overlooked. 

So slight are the symptoms at first that patients do not mention 
the neck trouble, and it is only by the habit of close observation that 
the surgeon himself does not let so serious a matter escape him. 
While no active symptoms referable to the neck-abscess may occur 
during the first few days, it often increases rapidly in size. The sur- 
rounding tissues become infiltrated; the tumefaction extends over a 
larger surface; the overlying skin becomes tense and shiny to such a 
degree as to suggest erysipelas; the movements of the head become 
restricted and painful; the temperature rises; the tongue becomes 
coated; headache, loss of appetite, and other febrile disturbances su- 
pervene. Although fluctuation does not occur early, especially if the 
abscess is deep-seated, the diagnosis is promptly suggested by the pres- 
ence of the suppuration above it. 

The only treatment is to open and evacuate the cavity and treat 
it antiseptically until pus formation ceases. Great care must be taken 
to avoid injury to the net-work of veins, arteries, and nerves in this 
region. For this reason it is best to open the abscess as far back as 
possible, and yet open it in a dependent position. Further treatment 
should be on general surgical principles. 

Fig. 115 shows such a case three weeks after the modified Stacke 
operation and opening of the neck-abscess, the latter being entirely 
healed. A drainage-tube was inserted into the neck-opening, carried 
upward, and brought out through the mastoid wound. 

Figs. 116 and 117 show an extraordinarily large abscess of the 
neck complicating mastoid and middle-ear suppuration. The swelling 
over the mastoid process is best shown in the front view. The great 
swelling of the neck is indicated by the curved line below the ear in 
the posterior view. 



CHAPTEE XVI. 

DISEASES OF THE INTERNAL EAR. 

As compared with, affections of the middle ear, diseases of the 
labyrinth are rare, except as sequels of tympanic diseases. The 
methods of making a differential diagnosis between these two parts 
of the ear are sufficiently set forth in the section on hearing-tests. 

Hyperemia axd Anemia of the Labyrinth. 

Hyperaemia may occur as a result of middle-ear inflammation or 
some intracranial disease, or secondarily to a disturbance of the cir- 
culation in the blood-vessels of the neck, such as pressure on the large 
veins, or it may be due to certain medicines, — quinine, sodium salicy- 
late, amyl-nitrite, etc. It sometimes complicates the fevers. 

Anaemia of the labyrinth may follow great haemorrhages, exhaust- 
ing affections, and various anomalies of the circulation. 

The symptoms need not necessarily include impairment of hear- 
ing, but tinnitus aurium and giddiness are the principal manifesta- 
tions. These conditions will be recognized as accompaniments to the 
main diseases which give rise to them, and the diagnosis, prognosis,, 
and treatment will be determined accordingly. If hyperaemia is due 
to active inflammation of the middle ear, the measures laid down in 
the section on that subject should be brought into requisition: co- 
caine, local bleeding, counter-irritation, catharsis, bromides, rest, the 
mastoid ice-bag (Fig. 83), etc. 

In anaemia of the labyrinth the primary condition that causes 
the anaemia will suggest the treatment. 

IXFLAMUATIOX OF THE LaBYRIXTH (OTITIS IxTERXA). 

Primary inflammation of the internal ear is of very rare occur- 
rence; but a disease of the surrounding structures, the middle ear, 
or mastoid process may extend to the labyrinth. An intracranial 
lesion also may involve this organ. Predisposing causes are to be 
found in the loss of the stirrup, caries and necrosis of the inner wall 
of the tympanic cavity, etc., by means of which an entrance of bac- 
teria and discharges is effected into the labyrinth. 

(183) 



184 INFLAMMATION OF THE LABYRINTH. 

Cases of primary labyrinthitis have been reported by Agnew, 
Schwartze, Webster, and others. Occasionally cases are seen in which, 
after a severe cold or some other cause, or even without any dis- 
cernible cause, sudden deafness of greater or less degree comes on, 
without traces of middle-ear disease. Giddiness usually accompanies 
such attacks. The dizziness may disappear, leaving a permanent deaf- 
ness. In case this deafness is due to a serous exudation into the laby- 
rinth, producing pressure on the terminal filaments of the auditory 
nerve, the loss of hearing may not be complete or permanent. Ab- 
sorption of the exudate may be followed by a clearing up of the 
subjective symptoms and deafness. 

Purulent inflammation is of more serious import, since it not 
only robs the sufferer of the power of hearing, but jeopards his life. 
Besides the predisposing causes mentioned above, it is sometimes a 
result of the eruptive fevers, diphtheria, mumps, variola, typhoid 
fever, or cerebral meningitis. The latter disease is simulated by the 
most active form of primary labyrinthitis. The two are easily mis- 
taken for each other, the symptoms are so similar, but the duration 
of the labyrinthal affection is but a small fraction of the other. 

Panotitis, or inflammation of both middle and internal ears, is 
generally the result of scarlet fever or diphtheria, producing irre- 
parable deafness and for some time a staggering gait. A separate 
description of this disease is not necessary, since it is a combination 
of two conditions already presented. 

The prognosis of inflammation of the labyrinth is unfavorable. 
Some cases recover; more do not. One such case, complicated with 
mastoiditis, recovered entirely after four months, without mastoi- 
dectomy, although I was in doubt for a time if further postponement 
of the operation were justifiable. Another became entirely deaf dur- 
ing meningitis at the age of 2 years. During the sixth year she began 
to distinguish sounds. She has improved under treatment, and has 
learned to talk without special instruction or lip-reading. At the 
present time, 1898, improvement continues. She hears conversation 
well, and attends the public schools. The author has met with a 
number of such instances; yet it is safest to give a very guarded and 
conservative prognosis. 

Treatment.— Potassium iodide, pilocarpine, iodine ointments, 
etc., have been used by Politzer, Moos, Gruber, and others. Of a 
2-per-cent. solution of pilocarpine hydro chlorate, 2 to 6 drops are 
injected into the forearm daily, in increasing doses. General anti- 



Meniere's disease. 185 

phlogistic treatment must be resorted to in the acute stage, such as is 
detailed in the division on acute inflammation of the middle ear. In 
syphilitic "infection the iodides and pilocarpine are indicated. In 
suppuration the methods given for middle-ear suppuration are ap- 
plicable. 

Hjemobehage ixto the Labyrinth. 

Extravasation of blood into the labyrinth may take place as the 
result of the same diseases that induce inflammation of this organ. 
as well as from atheromatous degeneration, fracture of the temporal 
bone, concussion, and necrosis. Eesolution may take place by absorp- 
tion, or an inflammatory process may be set up. with its train of con- 
sequences, or the clot may undergo organization. 

Meniere's Disease. 

Meniere first described a group of symptoms that characterized 
a case of effusion of blood into the labyrinth: deafness, vertigo, and 
vomiting. The attack comes on suddenly, the patient falling as in 
an epileptic seizure and presenting an appearance, on regaining con- 
sciousness, similar to one coming out of an epileptic fit. In addi- 
tion to the symptoms mentioned, there may be subjective noises and 
total deafness. After consciousness returns and vomiting ceases, the 
great deafness, dizziness, and tinnitus auriurn remain. AValking with 
the eyes closed is difficult and the body may incline toward the dis- 
eased side. The mental faculties evince impairment. 

Diagnosis. — This is based on the suddenness of the attack: the 
extreme loss of hearing without previous serious disturbance of func- 
tion; the presence of a group of symptoms pointing, in unison. 
toward aural disease: absence of disease of the conducting apparatus 
or of any other structure than the auditory nerve. 

Prognosis. — This, for the most part, is unhappy. The hearing 
may improve, but this is not likely. The dizziness soon diminishes 
sufficiently to allow the patient to walk, though unsteadily, and he 
staggers toward the side of the affected ear. The tinnitus may dis- 
appear, but is likely to continue indefinitely. 

Treatment. — Eest in bed and perfect quiet are important. The 
bowels should be relaxed, an ice-bag (Fig. 83) applied to the mastoid. 
and a counter-irritant to the side and back of the neck. Potassium 
bromide and iodide in large doses and pilocarpine may be employed 
as directed for labyrinthitis. Charcot recommended quinine, but, 



186 SYPHILIS OF THE INTERNAL EAE. 

since it produces labyrinthal congestion, it appears to the writer to 
be contra-indicated. 

Letjcocyth^mic Deafness. 

Patients suffering from leucocythaemia are sometimes subject to- 
sudden and complete deafness and vertigo, and even facial paralysis. 
The ear, like all the other organs, is subject to hemorrhagic and ex- 
udative processes, although it is not as frequently implicated as the 
eye. Inflammation may follow, resulting in proliferation of connec- 
tive tissue or bony growths. 

The treatment consists in measures for the general condition and 
the remedies recommended in Meniere's disease. 

Syphilis of the Labyrinth. 

Syphilitic lesions of the labyrinth are most likely to occur dur- 
ing the tertiary stage, but sometimes manifest themselves in the sec- 
ondary period. The precise pathological changes in this disease are 
not yet clearly established. The symptoms are very similar to those 
characterizing Meniere's disease. In most cases subjective noises are 
added to the great deafness and dizziness. The affection is usually 
bilateral. Bone-conduction is diminished or destroyed. The presence 
of syphilitic lesions in other parts of the body, or a history of a 
previous infection, combined with the symptoms referred to, clear up 
the diagnosis. Of all children with inherited syphilis, 10 per cent, 
have ear trouble (Hutchinson and Jackson). Others claim as high as 
33 per cent. The characteristic Hutchinson teeth should be looked 
for. 

The prognosis is unfavorable. In recent affections and in young 
persons the prospects are more encouraging than in the severe types,. 
with age and a generally impoverished condition to combat. 

Treatment. — This is the same as for constitutional syphilis, with 
the addition of pilocarpine injections, in 2-per-cent. solution, of 4 
to 12 drops in increasing daily doses. Any improvement to be had 
from the pilocarpine should show within two weeks. Edmund D. 
Spear speaks highly of the results from subcutaneous injections of 
pilocarpine. The writer generally employs the mixed treatment, — 
mercury and potassium iodide combined. 

Albert H. Buck cites a case of congenital syphilitic disease of 
the ears in a boy, giving rise rapidly to a high degree of bilateral 
deafness. The hearing was much benefited by treatment, which fact 



DISEASES OF THE AUDITORY NERYE. 187 

led the reporter to conclude that it was an instance of localized peri- 
ostitis affecting either the internal surface of the cochlea or the 
articular borders of the stapes and oval foramen. 

Max Toeplitz reports, in the New York Medical Journal, Octo- 
ber 7, 1893, a case of aural syphilis in which "the labyrinth was 
affected primarily in the course of a freshly-acquired case of syphilis. 
The aural affection began simultaneously with the appearance of 
roseola. 

"The special features of this case are as follow: 1. The affec- 
tion of the labyrinth occurred after the appearance of pharyngeal 
patches and simultaneously with the appearance of roseola. 2. The 
aural lesion took place during the secondary stage without attacking 
the middle ear. 3. The diagnosis of syphilis was made from the ear 
trouble. 

u The pathological changes produced by the syphilitic poison, 
which entered the lymphatic and blood-current of the labyrinth from 
the pharynx through the aqueduct and the blood-vessels, probably 
consisted in inflammatory alterations of the membranous portion, the 
periosteum and the surrounding lymph of the vestibule, and the first 
turn of the cochlea, with an increase of cellular elements and hemor- 
rhages. All these changes disappeared after energetic antiluetic treat- 
ment. " 

Diseases of the Auditory Nerve. 

The acoustic nerve may become the seat of various changes — 
hyperemia, hypertrophy, atrophy, secondary inflammation, and sup- 
puration — through invasion from the contiguous intracranial or tym- 
panic structures. It must be admitted that the present state of our 
knowledge of these pathological processes affords no basis for a prom- 
ising system of treatment. 

NEUROSES of the perceptive apparatus. 

Hyperaudition. — A transitory increase in the intensity of the 
hearing-power affects some persons. For this condition the author 
proposes the term "hyperaudition" as conforming to our system of 
nomenclature and as being correctly and briefly expressive. This con- 
dition is a symptom of cerebral excitement or irritation, and may con- 
stitute a precursor of intracranial disease. 

Hypersesthesia. — Auditory hyperesthesia is an insufferable sen- 
sitiveness to sounds or noises. Highly-nervous subjects often present 



188 PARACUSIS. 

this anomaly, and it is an accompaniment of headaches and intra- 
cranial affections. It is often observed in sclerosis of the middle ear. 
The slamming of a door, the firing of a gun, etc., cause much more 
discomfort than in a state of health. 

Paracusis. — This is a false perception of the pitch of sounds. The 
tone is heard by air-conduction generally higher than its true pitch, but 
may be heard lower. This may occur in one ear only, even when both 
are affected by sclerosis, and it is due to an abnormal tension of the 
transmitting mechanism. The writer has observed in such cases that 
certain tones only, and mostly the higher, were thus incorrectly per- 
ceived by one ear, both being similarly diseased, while all tones were 
correctly heard by bone-conduction. The apparent alteration in pitch 
varies in different subjects from one-quarter to one-half tone, or 
even one or two tones. This trouble unfits a musician for any but 
solo-playing. 

Double hearing has been observed in acute middle-ear inflam- 
mation. The tone was perceived as a primary, accompanied or fol- 
lowed by a secondary, sound, the latter being in the nature of an 
echo. This may be due to hearing correctly with the normal ear and 
incorrectly with the other. 

Paracusis Willisii. — This is hearing better in a noise, and is 
pathognomonic of sclerosis. It is undoubtedly due to the fact that, 
when powerful sound-waves set the ossicles in vibration, the lesser 
vibrations are carried along with the greater to the perceptive organ. 
Once arrived at the latter point, the smaller waves are recognized with 
the larger (see chapter on sclerosis). 

Subjective Sounds. — These are sounds experienced by the patient 
as real, but existing only in his own consciousness. They are not 
always referred to the ears, but to other parts of the head: the region 
immediately above the ears, the occiput, and even the vertex. They 
are due to irritation of the auditory nerve and possibly of the hear- 
ing-centre. Occasionally they are so intense that the sufferer is led 
to believe them to be objective sounds and that his friends ought to 
hear them by placing their ears close to his. They may become so 
unendurable as to cause melancholia and loss of sleep and memory. 
Even in greatly-impaired hearing and total deafness patients have 
declared to me that they would not care whether the treatment bene- 
fited the hearing, if only the interminable head-noises could be 
stopped. 

It is sometimes imagined that insects have gained entrance into 



SUBJECTIVE SOUNDS. 189 

the ears, and the surgeon is importuned repeatedly to look for them, 
being assured that they must he found. One woman persisted in her 
declarations that there were crickets in her ears, for she could hear 
their constant chirping. Notwithstanding my examinations, and state- . 
ments to the contrary, she rilled her ears with spirit of turpentine to 
kill the crickets. 

Very susceptible individuals may have their minds unbalanced 
by this harassing, unceasing din. vVe have seen instances in which 
subjective voices were heard, but they were hallucinations of hearing 
in persons of unsound mind. Whether the psychoses were attribu- 
table to the ear disease or whether the latter was merely a coincident 
could not be determined. The latter was probably true, and in such 
cases the tinnitus aggravated the mental aberration. Ear treatment 
may afford much relief in such nervous affections by removing the 
excitant of hearing-hallucinations. 

There is a wide variation in the character of the subjective 
noises. Most people call it a ringing or tinkling of high pitch. In 
others it is like the roaring of water, the sighing of the winds, the 
rumbling of wagons, crackling or explosive sounds, or sudden changes 
from the usual ringing to a loud breaking forth of a tone, as if a 
small bell had been struck a hard blow. The pitch of the ringing 
in one ear may be in unison with a fork of 2048 vibrations, or the 
third C above middle G of the piano, while the pitch of the tinnitus 
of the other ear may be much lower and the sound of a different 
quality. Probably in most cases it is like the ringing produced by 
overdoses of quinine. There may be two different qualities of sounds 
in the same ear. 

The noises are increased during a combination of low barometer 
with low thermometer, especially so when the air is very humid. 
Continuous cloudy or rainy weather and winds give rise to them. 
The same is true of quinine, sodium salicylate, alcoholic beverages. 
excessive tobacco-smoking, loss of sleep, sneezing, coughing, much 
use of the voice, very cold drinks or food, and a damp, cold, moldy 
atmosphere, such as is found in basements. On the other hand, warm, 
sunshiny weather diminishes the noises. They are less observed or 
entirely suppressed in the presence of objective sounds like those of 
an orchestra, the noises of the street or cars, etc. Often patients can- 
not tell whether or not the noises are present when objective sounds 
can be heard. When tinnitus first appears it may be intermittent, but 
in advanced sclerosis it becomes interminable. A certain tolerance 



190 SUBJECTIVE SOUNDS. 

of the noises is frequently acquired, so that they are not very much 
noticed when the individual is preoccupied or in a noisy locality; but 
in quiet surroundings the noises seem to besiege the brain again with 
redoubled intensity. 

Nervous tinnitus auriuni is an affection in which the ear is not 
of necessity involved. It may arise from reflex causes and requires 
general, rather than special, treatment. However, the ear should be 
inspected for any possible lesion. 

Spasmodic noises, or those occasioned by spasmodic contractions 
of the muscles of the ear, are rare. In one case I could plainly see, 
synchronously with the clicking noises, a rhythmical movement of 
the drum-head, — excursions inward and outward, — undoubtedly oc- 
casioned by spasmodic contractions of the tensor tympani muscle. 
Spasmodic contractions of the Eustachian tubal muscles may cause 
snapping sounds. Mucous rales occur in the Eustachian tube and 
middle ear in the same manner as they do in the bronchial tubes. 
Circulatory disturbances of the heart, the internal carotid artery, or 
the arteries of the ear give rise to pulsating sounds in unison with 
the pulse. 

Prognosis. — This depends principally upon the cause of the sub- 
jective sensations, but, excepting in sclerosis and diseases of the laby- 
rinth and of the brain, the prospect of relief is good. The longer the 
noises have existed, and the more unvarying and continuous^ their 
character, the less promising is the prognosis. 

Treatment. — Since tinnitus auriuni is a. symptom of various 
pathological processes, we can speak of its treatment here in a gen- 
eral way only, otherwise it would involve the measures necessary for 
the special treatment of all the causative conditions. These will be 
found in their proper divisions of the subject. 

It is much more difficult to stop the noises than to improve the 
hearing. The latter often increases, while the noises prove intract- 
able. We may diminish the noises or change their character, while 
we cannot by any known means eradicate them, in many cases. It 
is unwise to promise to cure or even to diminish them. In the ma- 
jority of instances the tinnitus is a 'symptom of sclerosis. In addi- 
tion to the treatment outlined for sclerosis the author has used coun- 
ter-irritation with mustard or its oil, and has vesicated with can- 
tharidal collodion. These applications sometimes produce a bene- 
ficial effect. When the tinnitus has continued after an acute inflam- 
mation of the middle ear has subsided, we have found medium doses 



PARESIS AXD PAEALYSIS OF THE AUDITORY XERVE. 191 

of sodium bromide afford complete relief. This was attributed to its 
sedative effect on the labyrinthal irritation. Charcot and Guye have 
recommended quinine. It may prove serviceable in periodical tin- 
nitus, but as it produces congestion of the middle ear and labyrinth, 
and, in large or continued doses, deafness, its utility in ear affections 
is very limited. 

Paresis a^d Paralysis of the Auditory Xerve. 

There are certain forms of paresis and paralysis of the auditory 
nerve that are so rarely met with as to merit only a passing notice in 
a work of such practical brevity as this. In some hysterical subjects 
anomalies of hearing and subjective noises occur, but in association 
with anaesthesia or hyperesthesia of other parts of the body that 
indicate the character of the affection. These attacks are transitory 
and without apparent changes in that part of the ear that is ac- 
cessible to inspection. 

Treatment of these aberrations is largely based on the associated 
causative conditions; but, in addition to the general treatment, special 
measures may be employed by means of the ear-electrodes (Fig. 77). 
The writer has generally preferred the primary current of a faradic 
battery to the galvanic, for the former unites the properties of both 
currents, as he has shown in his batteries by means of the galvanom- 
eter. The negative pole is connected with the electrode that rests 
in the ear which requires stimulation or irritation. The current is 
turned on very mildly at first and gradually strengthened until it is 
as strong as can be comfortably borne, and continued for six to ten 
minutes. By means of my electrodes the current is more limited to 
the ear than with the older kinds, which diffuse the current mostly 
over the side of the head. 

In using these electrodes it is not necessary to fill the meatus 
with water, as was the former custom, to the detriment of the drum- 
membrane, but the tips of the electrodes are moistened and covered 
with a wet layer of absorbent cotton. 

In treating paresis or paralysis of the facial nerve after a mas- 
toid operation the wound can be filled with wet cotton and the elec- 
trode placed in contact with it. This conducts the current to the 
injured nerve. The other electrode is held in contact with the op- 
posite mastoid process. During a part of the treatment the electrode 
is removed from the opposite ear and applied to the groups of mus- 
cles affected (Fig. 112). 



192 cerebral causes of deafness. 

Cerebral Causes of Deafness. 

Cerebral deafness may arise in two ways: by a disease of the hear- 
ing-centres or by an extension of a disease of the brain or of the 
meninges to the origin or course of the acoustic nerve or to the laby- 
rinth. The most frequent cause of intracranial deafness is menin- 
gitis. The loss of hearing may not become apparent at the time that 
it occurs, but it will be discovered when the patient regains conscious- 
ness. The destruction of hearing takes place within the first few 
weeks of the disease. This form of deafness is not amenable to treat- 
ment, the reason for which is apparent when we consider the patho- 
logical processes that destroy the function of the nerve: "Softening 
or thickening of the ependyma of the fourth ventricle, purulent in- 
filtration and softening of the auditory nerve" (Knapp); "imbedding 
of the latter in meningeal exudation" (Schwartze); "shriveling of the 
nerve-stem, and purulent inflammation of the membranous labyrinth, 
the origin of which can be traced to transmission of the inflamma- 
tion either along the sheath of the auditory nerve (neuritis descendens) 
or through the aqueducts" (Politzer). 

The majority of cases of deaf-mutes coming under my observa- 
tion in which the deafness was acquired were the result of meningitis. 
Politzer and Moos observed a staggering gait in half or more of their 
cases. 

We have not been able to verify the statement that tinnitus 
aurium is a frequent symptom, but most of my cases of deaf-mutes 
have been children, and they rarely speak of subjective noises. 

Treatment will be considered only briefly, for its effects are 
usually nil. If the patient is seen during the meningitis, the ice- 
bag (Fig. 83) should be applied over the ear as soon as there are 
aural symptoms. Later, if the deafness is not of too long standing, 
absorbents and alteratives should be tried, such as potassium iodide, 
and pilocarpine in a 2-per-cent. solution, 6 to 10 drops at an injection. 

Many pathological processes in the brain are capable of disturb- 
ing the Rearing. It has been observed repeatedly that a disease of the 
left temporal lobe, involving the first convolution, produces word- 
deafness. In this peculiar state there is a hearing for sounds, but in- 
capacity for interpreting the compound' sounds entering into the 
formation of words. This circumstance would tend to locate the 
cortical centre for hearing in this part of the brain. 

The most frequent cerebral cause of deafness is the presence of 
tumors. The symptoms are very like those of labyrinthal disease: 



NEW GROWTHS OF THE INTERNAL EAR. 193 

dizziness, tinnitus, varying degrees of deafness, and gastric disturb- 
ances. 

The diagnosis is often impossible. In the case of tumor, how- 
ever, facial paralysis may develop, and bone-conduction may not be 
obliterated as it is in the labyrinthal deafness. Tumors may also 
produce pressure affecting other nerves besides the acoustic or facial. 
Anaesthesia of the skin of the corresponding side of the head is some- 
times found. Symptoms pointing to involvement of the optic or other 
nerves may aid in arriving at a correct deduction. 

New Growths of the Internal Ear. 

New growths of primary formation in the internal ear have been 
met with but very infrequently, and clinically their consideration 
merits only brief mention. The presence of growths in this situation 
is usually due to an extension from the cranial or tympanic cavity 
of epithelioma or sarcoma. 



CHAPTER XVII. 
DISEASES OF THE INTERNAL EAR, CONCLUDED. 

Injueies of the Labyeinth. 

Penetbating wounds of the labyrinth are of infrequent occur- 
rence, but more often damage is done by fractures of the temporal 
bone, and concussion transmitted through the bones or through the 
air and conducting apparatus to the labyrinth. 

The symptoms of fracture of the bone are: a flow of blood and 
serous fluid from the ear, inco-ordination, deafness, and vertigo. The 
symptoms of concussion are the same, with the exception of the bloody 
and serous discharges. The author has seen quite a number of in- 
stances in which the symptoms of irritation or paralysis of the audi- 
tory nerve supervened upon blows on the skull or on the ear. In 
the latter, rupture of the drum-head generally was present when the 
cases were seen early, and in such instances the labyrinthal symptoms 
were not as severe as when the drum-head was not ruptured, for in 
the latter case the force of the concussion was spent mostly on the 
stirrup, probably impacting it into the oval window. I have exam- 
ined many soldiers of the war between the States, who suffered more 
or less loss of hearing from concussions produced by cannons, ex- 
ploding shells, etc., in battle. Instances have also come under my 
observation in which blows on the head from the "sand-bags" of rob- 
bers, and from other weapons, and concussions from falls, have pro- 
duced total deafness. Many workers in boiler-shops have appeared 
at the clinics with great dullness of hearing and tinnitus. Their ears 
were generally full of hardened, impacted plugs of black wax. After 
removing these the impairment of hearing still remained of high 
degree. Blacksmiths, tinsmiths, coopers, and iron-workers suffer 
similarly. This is due to the constant concussions of the drum-head, 
ossicles, and intralabyrinthal fluid and the auditory nerve from their 
incessant hammerings. The effect is to produce, in addition to the 
labyrinthal affection, the sclerotic form of middle-ear catarrh, which 
has already been considered. 

Treatment of these forms of disturbances of hearing, of co-or- 
dination, etc., is generally of little or no avail if several months or 

(194) 



DEAF-AUTISM. 195 

years have elapsed since the injury. In the early stage succeeding 
the concussion, the treatment laid down for tinnitus aurium and for 
paralysis of the acoustic nerve is indicated. 

Deaf-mutism. 

This is the lack or loss of speech due to congenital or acquired 
deafness. In my experience it is a rare condition. Only 1 / 2 of 1 per 
cent, of all the cases of ear-defects that the writer has studied in 
hospital, dispensary, and private practice are of the deaf-mute class. 

Pathology. — In congenital deaf-mutism the precise condition to 
which it is due cannot be determined. This subject presents an 
opportunity for the application of the theory of reversion as affect- 
ing types of degeneracy. It may be owed to lack of development in 
some part of the organ of hearing, deformities of the fenestras of 
the labyrinth, hydrocephalus, or pathological changes in the course 
or origin of the acoustic nerve. The acquired form may be due to 
middle-ear sclerosis, necrosis of the labyrinth, auditory neuritis, men- 
ingitis, or cerebritis. The tympanic and labyrinthal cavities may be 
entirely obliterated by connective-tissue and osseous proliferation. 
If the hearing is lost under the fifth year there is no speech, because 
it has not been acquired, while speech which has already been ac- 
quired later in life may be more or less perfectly retained after hear- 
ing is lost. However, I have many times observed that even in deaf- 
mute infants the primitive words "mamma" and "papa" only are 
uttered. 

I have known dumbness to follow the loss of hearing even after 
speech was acquired. The ability to articulate words gradually de- 
clined until nothing more than mumbling and mouthing of unin- 
telligible sounds remained. In about 50 per cent, of deaf-mutes the 
semicircular canals are affected, which accounts for their peculiar, 
straddling gait, the feet being kept wide apart, and for their inability 
to stand with their eyes closed, and especially on one foot. 

Among the 158 deaf-mutes of the institution for this class at 
Prague, Frankenberg (American Medico- Surgical Bulletin, December 
10, 1897) found 94, or 59 per cent., with adenoid vegetations in the 
vault of the pharynx large enough to fill this space. Of these, 56 
were boys and 38 girls. In 69 of these cases there were anomalies of 
the ears as follow: Impacted cerumen, 21; chronic suppuration with 
granulations, 11; sunken drum-head, 12; stenosis of the external 
meatus, 1; atresia of the meatus, 1; foreign body in the meatus, 1; 



196 DEAF-MUTISM. 

adhesion of the drum-head to the internal wall. of the middle ear, 1; 
hyperemia of the drum-head, 4; dry perforation of the drum-head, 
3; absence of the membrana tympani due to suppuration, 4; polypi, 
3; mastoid cicatrix from periostitis, 1. Of these cases, 37, or 53.6 
per cent., had adenoids. 

These facts indicate the importance of examining for these 
growths in children having ear affections. Arslan found 6 deaf- 
mutes among 426 cases of adenoids, and cured one and relieved 
another, with respect to both the hearing and speech, by the adenoid 
operation. 

In 118 autopsies on deaf-mutes performed by Mygind there were 
evidences of middle-ear diseases in 79. There were only 19 that were 
free from pathological conditions of the labyrinth or nervous centres. 
"In most of the cases the changes were due to severe and extensive 
inflammations, especially in acquired deaf-mutism. Other anomalies 
were almost identical in the two classes of cases, congenital and ac- 
quired. The opinion hitherto accepted that deaf-mutism results from 
congenital deafness, due to some anomaly of development of the organ 
of hearing, is invalidated by the fact that anomalies are of very great 
variety. Changes usually affect both ears, though unequally. The 
middle ear has been found most often affected. The internal ear 
was affected most in the semicircular canals, rarely in the vestibule; 
and in a great number of deaf-mutes these anomalies could be con- 
sidered the chief cause of the deaf-mutism. In some cases the audi- 
tory nerve presented phenomena of atrophy and degeneration, but 
more often the nerve was intact. In some cases there were anomalies 
of the brain." (Medicine, January, 1898.) 

Etiology. — Congenital deaf-mutism may be due to heredity, but 
it is not a frequent occurrence. A constitutional predisposition to this 
defect exists in some families, several members of which are afflicted. 
In one family the healthy parents had five daughters with normal 
senses and six sons who were born deaf (Kramer). Among all the 
deaf-mutes the writer has examined he does not know of one whose 
parents were deaf-mutes, although some have had various middle-ear 
affections. Consanguineous marriages, as well as specific disease and 
intra-uterine influences, are believed to account for deaf-mutism in 
quite a large proportion of instances. The acquired form may follow 
injuries during childbirth or infancy, meningitis, scarlatina, typhoid, 
diphtheria, mumps, syphilis, or inflammation of the labyrinth. I have 
not seen the epidemic influenza, or grip, given as a cause, but I have 



TREATMENT OF DEAF-MUTISM. 197 

had recently under treatment the ease of a girl, 6 years of age, who 
had lost her hearing entirely for four years in consequence of an at- 
tack of the grip. Under treatment the hearing has returned suffi- 
ciently at the present time to enable her to hear ordinary conversa- 
tion and to learn to speak intelligibly. Inspection revealed no change 
in the drum. 

Symptomatology. — In infants the defect is not likely to be dis- 
covered until about the time that children begin to talk, and even 
then it may be overlooked by the parents, who attribute the back- 
wardness to slow development. We have often observed that parents 
believed their children could hear and that some defect in the organs 
of speech accounted for its absence, and yet they were born deaf- 
mutes. Failure to respond to sounds and calls can be easily detected 
if tests are made in such a manner as not to attract the child's at- 
tention by movements within the range of vision. Calling its name 
from behind, clapping the hands in such a position as not to pro- 
duce waves of air that will strike the child, and out of its sight, the 
tuning-forks (Fig. 14), the Delstanche whistle, etc., are conclusive. If 
the child hear vowel or other sounds, a change of expression, a light- 
ing up of the countenance, smiles, etc., evince the fact. 

Diagnosis. — The means of diagnosis have been indicated above. 
In a large proportion of cases a modicum of hearing is present. The 
ability to say "mamma" is not significant, since it is frequently pres- 
ent in hopeless cases. Such sounds are primordial and are uttered 
by the lower animals. 

Prognosis. — AYhile the writer has seen apparent improvement in 
a few cases of congenital deaf-mutes, it has not been of such a 
degree as to admit of understanding the common conversational 
tone. Loud sounds and some words could be appreciated, without 
doubt, but even this slight gift proved a pitiful source of happiness. 
A few cases are on record in which there was a useful development 
of the hearing after about the sixth year or after puberty. The ac- 
quired form is generally regarded as less promising still. 

Treatment. — In many cases examined by me there were evi- 
dences of middle-ear dry catarrh, but whether this bore any signifi- 
cant relation to the absence of hearing-power was a debatable ques- 
tion. It is possible that middle-ear disease in early infantile life may 
have involved the labyrinth in a destructive inflammatory process; 
or, if the labyrinth has escaped, connective-tissue proliferation or 
osseous growths may have obliterated the round window and may 



198 EDUCATION OE DEAF-MUTES. 

have anchored the stirrup in the oval window so firmly as to pre- 
clude the possibility of its vibratory movements in response to sound- 
waves. If the auditory nerve is not destroyed, bone-conduction of 
sound can be demonstrated. In that case inflation of the middle 
ear and the application of the massage otoscope (Fig. 8), together 
with the galvano-faradic current (Fig. 77), may demonstrate the pos- 
sibility of improvement after a few weeks. In one case of a young 
man with greatly-thickened and retracted drum-heads, I resected 
parts of them, which resulted in a considerable improvement. He 
had already been able to perceive the sounds of the vowels, and after 
the operations he acquired the use of quite a number of words be- 
fore leaving the city. 

Special instruction of deaf-mutes should begin as soon as it is 
shown that there is no hope for the hearing. The younger the pupil, 
the greater the accomplishment in the schooling. During the World's 
Fair in Chicago great proficiency was shown in the attainments of 
very young children in lip-reading and articulate language in the 
school-exhibits of those who had never heard. The perfect discipline 
was something to be appreciated by those who have had much ex- 
perience with the deaf-mute class. Indeed, the author has often been 
led to a correct diagnosis in deaf-mute children before an examina- 
tion was made, and before any information was imparted, by their 
irritable temper and incoherent violent actions. Lip-reading and 
articulate speech should always be taught them, if possible, and the 
sign-language should be made an accessory. Some children do not 
acquire the former; so the latter must be employed. The admirable 
schools for the deaf in Chicago and other large cities go further and 
impart a useful education and more or less manual training in order 
to render their graduates self-supporting. 

M. A. Goldstein has published {The Laryngoscope, June, 1897) 
the excellent results obtained by the method of Urbantschitsch in 
persistent teaching of deaf-mutes by speaking vowel sounds, con- 
sonants, and their varying combinations into their ears until they 
are able to understand and repeat words and sentences. The author 
can recommend this method from practical experience with it. 

The education of the deaf should be no more neglected than that 
of the better favored of our race. Indeed, greater facilities should 
be afforded for the acquisition of an education and the acquirement 
of the prerequisites of good and useful citizenship, to counterbalance 
the unfortunate disadvantage at which they have been placed through 



HEARIXG-IXSTROIEXTS. 



199 



no fault of their own. The means already enumerated are efficient. 
They are provided by private and public schools in the cities, and by 
the States in their deaf-and-dumb asylums. The formation of classes 
in the public schools of cities for the instruction of partially-deaf 
children is advocated by H. A. Alderton (The Laryngoscope, August, 




Fig. 118. — The conical conversation-tube. 

1896). The subjects are usually intelligent and quick-witted, and 
their proper care and training will insure adequate returns upon the 
investment from both economic and humanitarian considerations. 

Hearixg-ixstroiexts. 

Of all the various devices for aiding the hearing two only have 
proven of actual practical value in my experience. They are the 
conical conversation-tube (Fig. 118) and the London horn (Fig. 119). 




Fig-. 119. — The London horn. 



The conversation-tube consists of a trumpet-shaped mouth-piece to 
collect the sound-waves, connected with an ear-piece — both being 
of hard rubber — by a conical, elastic, spiral-wire tube covered with 
rubber and woven silk. The mouth-piece is placed close to the lips 



200 ARTIFICIAL AIDS TO HEARING. 

of the speaker, when a low, conversational tone can be employed, 
enabling the listener to hear words that are inaudible to others. The 
speaker should never talk loudly or cough or clear his throat with 
the month-piece near his lips, for often the hypersensitiveness of the 
affected ear renders these harsh, explosive sounds painful and irri- 
tating. These tubes are generally worn about the neck, nncler the 
coat, or rolled up in the coat-pocket. For near conversation they 
are, by far, superior to any other device. 

The London horn (Fig. 119) is an excellent instrument for use 
at long distances, as in the church or lecture-room. It is made in 
three sizes and painted a dead-black preferably. The nickel-plated 
instruments are far more conspicuous. The horn is applied to the 
ear as in the case of the tube, and the large, open end is directed 
toward the source of sound. There is one serious objection to the 
metal horns: they convey a metallic, adventitious sound along with 
the principal sound. This defect is especially noticeable in listening 
to singing and the playing of an orchestra. However, it is preferred 
to the tube by many. The most distinguished of American news- 
paper editors is entirely dependent upon it, and cannot be prevailed 
upon to try the tube. 

After an extensive destruction of the drum-head the hearing is 
sometimes much improved by placing a pledget of cotton lightly 
against the handle of the mallet. Sound-waves striking this are then 
communicated to the ossicles and so transmitted to the perceptive 
apparatus. In such cases the artificial ear-drum, consisting of a thin 
disc of soft rubber (TurnbiuTs), is inserted into the meatus and nicely 
adjusted to the exposed mallet. 

The audiphone, consisting of a fan-shaped disc of vulcanized 
rubber, bent by a silken cord into a convex surface to be presented 
toward the source of sound, the edge in contact with the upper teeth, 
has been used to some extent. The writer has tested it with numer- 
ous patients, but with few exceptions it was of little value. 

The rubber disc, apparitor auris, cornets, auricles, cones, etc., 
made of soft rubber and advertised extensively in the newspapers, are 
generally of no use to patients, and are provocative of irritation, in- 
flammation, and even ulceration of the canal and tympanic membrane 
and cavity. Occasionally we have been told by the wearers that their 
hearing was better while these devices were in their ears. We have 
frequently found them in contact with the drum-head, bathed in de- 
composing pus. 



ARTIFICIAL AIDS TO HEARING. 201 

Xo efficient and harmless liearing-instrnment for wearing in the 
ear has yet been devised. Fame and fortune await the inventor of 
the aural equivalent of spectacles. Alexander Graham Bell related 
to me that he discovered the useful principles of his telephone while, 
endeavoring to invent a microphone to aid the deaf to hear. In 
response to my question. "Do you not consider it possible to con- 
struct an instrument for defective hearing that will be comparable 
to the lens for defective vision ?" Mr. Bell replied, "I will not say 
that it is impossible; but, in the present state of our knowledge, it 
is improbable/' 



PART II 



Diseases of the Nose. 



(.203) 



PLATE II 



PLATE II. 



Vertical anteroposterior section of the nasal cavities, mouth, pharynx, and 
larynx. 

1. Frontal sinuses. 

2. Superior turbinated body. 

3. Sphenoid sinuses. 

4. Middle turbinated body with posterior hypertrophy. 

5. Adenoid growths. 

6. Inferior turbinated body. 

7. Orifice of the Eustachian tube. 

8. Fossa of Eosenmiiller. 

9. Oral tonsil. 

10. Epiglottis. 

11. Vocal cord. 

12. Trachea. 

The mirror and line of reflected light illustrate laryngoscopy. 



PLATE II 




CHAPTER XVIII. 
DISEASES OF THE XOSE. 

Examination and Instruments. 

Bhixological practice requires an illuminating apparatus like 
the one shown in Fig. 5, or the electric forehead-lamp, or a student- 
lamp. Fig. 120 shows an electric light attachable to a portable bat- 
tery. It consists of a cylinder, telescoping, from one and one-half to 
two inches (four to five centimetres) long, and is five-eighths of an 




Fig. 120. — Electric illuminator, as used in posterior rhinoscopy. 

inch (sixteen millimetres) in diameter, provided with two powerful 
lenses. This instrument, when lighted, throws a white light of six- 
to eight- candle power directly upon the object in the focus. This 
illuminator is particularly adapted to the wants of the specialist. By 
removing it from the head-band it may be used as a hand-illuminator 
in examining other cavities of the body. The examiner should sit 
sidewise by the patient, immediately in front and facing him. using" 

(205) 



206 EXAMINATION AND INSTRUMENTS. 

the three-inch forehead-mirror, which is shown in Fig. 4. Eeflected 
light only can be used to advantage in this practice. The surgeon 
should wear the mirror in front of his eye so as to look through the 
perforation in the glass, and in such a manner as to shade both eyes 
from the light. The room is best darkened in order to avoid the con- 
tracting effect of the light on the pupils of the surgeon's eyes. 

During the examination of the nose, one hand of the operator 
should rest on the top of the patient's head so as to control and 
manipulate its movements as is necessary in order to bring all the 
parts to be examined into the field of vision. 

The instruments required for anterior rhinoscopy are a nasal 




Fig. 121. — Nasal speculum of correct pattern, and the proper way to handle it. 

speculum (Fig. 121), a long cotton-carrier (Fig. 9) to remove secre- 
tions that obstruct a view of the parts, and a bent long probe for 
searching out hyperaesthetic areas and determining the contour and 
extent of anomalies. 

The nasal speculum is best held in the palm of the hand with 
the back of the fingers directed toward the patient's chin. The handle 
of the speculum should project straight outward and downward from 
the bivalves, so as to leave sufficient room between the patient's chin 
and the surgeon's fingers. The valves should be small enough at 
their tip to use with children. In manipulating the speculum the 
pressure ought to be exerted mainly on the soft, yielding ala of the 
nose, and not on the septum. De Vilbiss has devised an excellent 



ANTERIOR RHINOSCOPY 



20 r 



self-retaining nostril-dilator to be held in place by a rubber band 
about the head. 

Anterior rhinoscopy, or the examination of the anterior nares, 
reveals the anterior extremities of the turbinated bodies and the side 
of the septum. The patient's head is tilted backward or forward, as 




Fig. 122. — Boswortlrs tongue-depressor. 

the upper or lower parts of the nasal cavities are to be inspected. 
In many instances we can obtain a clear view entirely through the 
naris to the vault and posterior wall of the pharynx. In others, hy- 
pertrophies of the turbinated bodies or of the septum or deflections 
of the latter occlude the view. 

In health the color of the mucous membrane covering; the lower 




Fig. 123. — Throat-mirrors. 



portions of the naris is a light pink; that of the superior turbinated 
body and roof of the nasal arch is yellowish. The nature of the light 
furnishing the illumination may vary the shade considerably. 

Posterior rhinoscopy calls for the use of a tongue-depressor (Fig. 
122), rhinoscopic mirrors (Fig. 123), and occasionally a palate-re- 



208 POSTERIOK KHIXOSCOPY. 

tractor (Fig. 124). The tongue-depressor should not be inserted far 
enough to cause retching, and the patient is told not to resist the 
gentle pressure and not to gag. His co-operation aids materially in 
the examination, and only a little practice is necessary to success. 
When the rhinoscopic mirror is introduced, the tongue-depressor is 
held by the left hand and the mirror by the right. Just before in- 
troducing the mirror it is warmed by passing it with the glass side 




Fig. 124.- — White's palate-retractor. 

downward over the lamp for an instant only, to avoid the condensa- 
tion of the patient's breath on it, which would prevent a reflection of 
the post-nasal image. If the mirror is too greatly heated its back- 
ing is destroyed. A better method, which the author has employed 
satisfactorily for a considerable time, is to cover the glass surface of 
the mirror with liquid soap, and then polish it with a dry cloth. 
This soft soap prevents the breath from condensing on the glass, and 
renders the use of heat unnecessary. I have used Lee's liquid soap 
for this purpose. 

With the light reflected into the throat by the forehead-mirror,, 
the nasal mirror is carried over the depressed tongue until it nearly,. 




Fig. 125. — Hard-rubber palate-elevator. 

but not quite, touches the posterior pharyngeal wall with the mirror- 
surface directed upward and forward (Fig. 126). The natural in- 
clination is to breathe through the mouth when it is open, and the 
patient is directed to breathe through his nose so that the soft palate 
will fall forward and downward from contact with the post-pharyn- 
geal wall. Then, with the light properly directed upon the mirror, 
an image of the posterior nares should be seen. If the palate still 
embarrasses the view, it can be lifted and drawn slightly forward by 



POSTERIOR RHINOSCOPY. 



209 



the palate-elevator (Figs. 124 and 125). Painting the uvula and 
velum with a 4-per-cent. solution of cocaine or eucaine will facilitate 
this procedure. The rubber elevator is convenient. It is placed so 
as to lift the uvula with the soft palate, and the handle is held a 
little to one side, so as not to obstruct the field of vision. 

As large a mirror should be used as the space will permit (one- 




Fig. 12G. — The posterior rhinoseopic image. (After Bosworth.) 



half to three-fourths of an inch — thirteen to nineteen millimetres), 
but it must be small enough not to necessarily come in contact with 
the surrounding parts and produce gagging. The mirror is so manip- 
ulated as to bring the plane of its surface at an angle of about sixty 
degrees to the perpendicular plane of the posterior nares, in order to 
obtain a perfect image. 



210 



SPRAY-PRODUCERS. 



The first reflected image to attract the attention is that of the 
velum palati. By slightly changing the position of the mirror, the 
septum on the one side and the orifice of the Eustachian tube on the 
other come prominently into view/ with the posterior ends of the tur- 




Fig. 127.- — The Davidson spray-producers. 

binate bodies in the centre of the field. The two lower ones, of a 
light-pink hue, are easily distinguished; but the superior body, yel- 
lowish and dimly outlined in its remote recess, is not so easily seen. 

The vault of the pharynx is rendered visible by tilting upward 
the mirror-handle in varying degrees until one obtains an image of 
the pharyngeal tonsil. It is often necessary to cleanse the nasal pas- 
sages with the detergent solutions before a complete inspection can 
be made. 

The Davidson atomizers (Fig. 127) are very convenient for 




Fig. 128. — The De Vilbiss atomizer 



cleansing and medicating the nares. They throw a very coarse spray, 
bathing the parts profusely. They hold a large amount of fluid, do 
not leak, and are supplied with both straight and curved tips for the 
naso-pharynx and larynx. The De Vilbiss atomizer (Fig. 128) has 



ATOMIZERS. 



211 



an excellent adjustable tip. It can be turned so as to throw the 
spray in any direction desired, from the posterior nares to the larynx. 
His latest device to be used with compressed air has a flange upon 




Fig. 129. — The lavolin atomizer. 

which the fingers rest to prevent the column of air from throwing 
the instrument out of the grasp. It is made with a broad base so as 
to prevent it from tipping over, and it can be used with the hand- 
bulb also. The lavolin atomizers (Figs. 129 and 130) are very con- 




Fig. 130. — Truax, Greene & Company's atomizer 



venient for home treatment. We often prescribe these with a 3-per- 
cent, solution of camphor-menthol in lavolin or benzoinol for patients 
to use at bed-time, to aid in the treatment. By this means they keep 



212 



ATOMIZERS AND VAPORIZERS. 



the upper respiratory passages cleansed and protected and they are 
more faithful to the treatment. The results are more satisfactory 
with this method. 

My assistant, A. H. Andrews, has recently devised an atomizer 
which will produce both coarse sprays and fine vapors, and it can be 
operated by a rubber bulb or by the compressed-air apparatus (Fig. 
131). 

Many devices are employed for treating the nasal cavities, but 
few are necessary. Some are capable of doing actual harm. The 
Weber nasal douche has thrown watery solutions through the Eusta- 
chian tubes into the middle ears, setting up an inflammation. This 




Fig. 131. — Andrews's combined atomizer and vaporizer. With the nasal 

tip lightly adjusted a fine vapor is produced; with it firmly 

pressed upon the spray-tube, a coarse spray results. 



is especially liable to happen when any stream of fluid is passed into 
the nostril, for there is a strong inclination to swallow, provoked by 
the presence of the liquid. In the act of deglutition the orifices of 
the tubes open and allow the entrance of the fluid into the tympanic 
cavities. One of the most useful instruments for medicating the re- 
spiratory passages, after they are properly cleansed, is shown in Fig. 
132. It consists of a nebulizer which projects the most finely dif- 
fused spray obtainable, and admits of the use of much stronger 
medicaments than are ordinarily used. It is so constructed that the 
medicament from one of the nebulizing globes (JE) can be propelled 
into the nose, throat, or middle ear in a steady current, or with in- 
terrupted currents by tapping on the valve (I). Or the inhalents in 



VAPORIZERS. 



213 



two or all of the nebulizing globes can be combined and used at the 
same instant. 

An important addition to this vaporizer is the air-regulating 
collar below the push-button (I). By this device the amount of press- 
ure is easily controlled and shut off altogether, if desired, when the 
interrupted current is employed for inflating the middle ears. 

The compressed air is supplied to the circular tube (H) by means 
of attaching the cut-off of the air-reservoir at K. The air is admitted 
to the globes by opening the keys at G. 




Fig. 132. — The Universal vaporizer. 



For those practitioners who are not supplied with a compressed- 
air apparatus the Globe nebulizer (Fig. 133) is an excellent substitute 
for the large vaporizer. It is also fitted for use with compressed air 
and is employed in the same manner as the vaporizer. Fig. 134 repre- 
sents an inhalation taken through the aseptible face-mask. Fig. 
135 shows the inhalation through a small vulcanite mouth-tube, and 
in Fig. 136 the returning medicated vapor is seen to issue from both 
nostrils. Figs. 137 and 138 illustrate the medication of the nasal 
passages and vault of the pharynx by permitting the vapor to enter 



214 



NEBULIZERS AND INHALATIONS. 



one nostril and return through the other or through the mouth. In 
Fig. 139 the opposite naris is closed while the vapor is made to in- 
flate the middle ears, as we have already described. 

With such perfect instruments as are here shown, and with suffi- 




Fisr. 133.— The Globe nebulizer. 



cient air-pressure, the most effective treatment is rendered possible 
with accuracy and ease. Homer M. Thomas has demonstrated by 
experiments in Cook County Hospital that a vaporized medicament 
penetrates into the pulmonary alveoli of the human lung. He writes: 





Fig. 134. 



Fig. 135. 




Fig. 136. 






Fie:. 138 



Fig. 139 



"I have repeatedly seen good results in the treatment of localized in- 
flammations of the bronchial tract, by inhalation, as far as the second 
division of the bronchi. I have obtained results in that way that I 
have repeatedly failed to secure with internal medication. It is sur- 



SPRAYS AXD IXHALEXTS. 215 

prising how the respiratory ability can be increased by a little in- 
struction and effort.'* (The Laryngoscope, Xovember, 1897.) 

Sprays axd Ixhalexts. 

I have devoted considerable time to the investigation of inhalents, 
and have endeavored to arrive at definite results. "We know well the 
action of nitrate of silver or sulphate of zinc when applied to mu- 
cous membranes, but accurate studies have not been sufficiently de- 
voted to the physiological actions of the large number of inhalents 
offered for our use. 

These actions should be determined before we apply a local 
remedy to a diseased surface, for the same reasons that no internal 
medicine should be administered without fulfilling a special indica-- 
tion for its use. 

In the case of camphor-menthol we have no doubt as to its place 
in therapeutics. We have defined its actions: It contracts the capil- 
lary blood-vessels of the mucous membrane, reduces the swelling; 
relieves pain and fullness of the head, or stenosis; arrests sneezing, 
checks excessive discharges, and corrects perverted secretions. We 
know, also, that it possesses antiseptic qualities. 

Since my introduction of this remedy at the meeting of the Mis- 
sissippi Valley Medical Association, in 1891, it has come into quite 
general use for catarrhal conditions of the upper respiratory tract. 

Although the author did not recommend it until long after he 
had discovered that the union of these two camphors resulted in a 
fluid of the chemical formula C 10 H ls O, and after becoming satisfied 
that we possessed a valuable remedy in this new drug, he is now able 
to express greater confidence, and to verify former statements by. the 
experience of others as well as by the daily use of it up to the present 
time. The experimental stage has passed and the efficacy of this 
remedy is clearly established. Specialists who were at first skeptical 
as to its virtue have since adopted it as a standard remedy in both 
private and dispensary practice. I have taken pains to ascertain the 
results of their experiences, and add them to my own 

Pure camphor-menthol is the product resulting from bringing 
together equal parts of gum-camphor and menthol crystals without 
heat. They soon form a colorless liquid by uniting in nearly equal 
parts. This pure camphor-menthol is used in combination with 
lavolin or benzoinol in various strengths for producing sprays and 
vapors. Lavolin is a purified, colorless, petroleum-oil. Benzoinol is 



216 SPRAYS AND INHALENTS. 

a similar oil, with the addition of benzoin. The former is manufact- 
ured by Truax, Greene & Company, of Chicago; the latter by the 
Benzoinol Company, of New York. 

The field of application in which camphor-menthol has proved 
most efficacious is in the following diseases: Coryza, hay fever, in- 
tumescent rhinitis (intermittent and alternating nasal stenosis), hy- 
pertrophic rhinitis, simple sore throat, acute laryngitis, tracheitis, 
bronchitis, and after nasal cauterization to prevent hemorrhages and 
inflammation. 

For home use and ordinary office treatment we do not employ 
a stronger solution than the 3 per cent, in lavolin or benzoinol, and 
for very sensitive cases, like hay-fever sufferers, the 1- or 2-per-cent. 
solution at first. The lavolin is a bland and soothing protective to 
the membrane, and in the combinations indicated we have a most 
effective and harmless remedy. This means a great deal to both pa- 
tient and physician, for many of the sprays in use give indifferent 
results: — or worse. 

Patients should be instructed to treat themselves thoroughly 
every night on retiring, by throwing a spray of the 3-per-cent. solu- 
tion from an atomizer (Fig. 129) into both nostrils while slowly in- 
haling. The rubber bulb should be forcibly and rapidly compressed 
at least eight times for each nostril. For the throat, larynx, or bron- 
chial tubes the spray should be thrown through the mouth during 
inhalation. 

In diphtheria, croup, etc., in infants, when it is very difficult to 
throw a spray into the throat, the medicine may be made to reach the 
parts in a volatile form by placing a few drops of the pure, undiluted 
camphor-menthol in a hot-water inhaler (Fig. liO) or a tea-kettle of 
hot water and causing the patient to breathe the medicated steam; or 
a few drops can be heated in a spoon over a lamp, and its fumes will 
impregnate all the atmosphere of the room. Enough medicine need 
not be used to cause uncomfortable smarting of the eyes. Inflamma- 
tion of the throat, larynx, trachea, and bronchi can be effectually 
treated by inhaling the camphor-menthol steam in this manner. 

The writer has found that we can prevent haemorrhage and in- 
flammation, following galvano-cauterization of the turbinated bodies, 
by gently packing a pledget of cotton wet with a 10-per-cent. solution 
of the camphor-menthol between the burned tissue and the septum, 
and leaving it there twenty-four or forty-eight hours. It is then re- 
placed by a fresh dressing, and, at the end of four or five days, instead 



IXHALEBS. 



21? 



of finding sloughs filling the passages, swelling, and stenosis, the tis- 
sues appear shrunk and mummified and the strait is clear. Unless 
the electrode has been allowed to eool before removing, no haemor- 
rhage or only slight oozing occurs. There is also less discomfort fol- 
lowing this method than after others. The cotton should not he 
saturated to the dripping point with the solution, so as to allow it 




Fig. 140. — Hot-water inhaler. 

to trickle down into the throat, and if too much is used it occasions 
a copious serous secretion. Advantage of this power of the strong- 
solution to cause stimulation of the glands and osmosis can be taken 
in treating ozsena and dry catarrh of the nose and throat. The weak 
solutions diminish secretions; the strong ones increase them. 

For self-treatment of the nose and throat patients have found 
much relief by using an inhaler like that shown in Fig. 141, which 
can he carried in the pocket, and contains a liquified mixture of equal 




Fig. 141. — The author's camphor-menthol inhaler, 



parts, by weight, of camphor and menthol. It has a more soothing 
and correcting effect on the nerves and vessels than menthol alone. 
It does not become irritating, like menthol-crystals, after being used 
for some time. It can be used unnoticed in public places the instant 
any irritation appears, and thus prevent or cut short attacks. Three 
or four slow, deep inhalations should be taken from it in one nostril 
while the other is closed, or until the irritation is relieved. The 



-18 SPEAYS AND INHALENTS. 

breath should not pass through the inhaler, but out through the 
mouth instead. To treat the throat it should be inhaled through the 
mouth. 

If we want a drying, detergent, and protective spray, the pine- 
needle oil in a 2-per-cent. solution will accomplish the purpose, and 
it is a most agreeable preparation. In those rare cases in which the 
mucous glands are atrophied and in need of a powerful stimulant to 
excite them to action, the 4- or 10-per-cent cubeb-spray is the most 
effective, especially when combined with the 10-per-cent. strength of 
camphor-menthol and benzoinol. 

There is a, prevalent mistaken opinion that the cubeb-spray is 
drying to the mucous membrane, while the opposite effect is the true 
one. It is a stimulant and disinfectant. It increases the flow of 
mucus, and if used in too strong a preparation it acts as an irritant. 
Cubeb is useful as a tonic in chronic irritability of the pharynx and 
larynx, especially in the hoarseness of public speakers and singers. 

Eucalyptol is antiseptic, and destructive to low forms of life. It 
is a stimulating expectorant, and must not be used in very strong 
solutions, or it becomes an irritant. When combined with benzoinol 
in the proportion of 20 grains to the ounce it is not too strong for 
the majority of patients, but, as a rule, it must be avoided in hay- 
fever patients. Some of them cannot remain in the room where it 
is being sprayed without suffering from paroxysms of sneezing. Car- 
bolic acid combined with benzoinol, 2 grains to the ounce, is valuable 
when the antiseptic and anaesthetic effects are required. It is very 
useful in ozama, especially when followed with aristol or nosophen. 

Antiseptic aqueous solutions are necessary for properly washing 
out and cleansing the nasal cavities preparatory to the application of 
other medicaments. DobeH's solution is the most universally used. 
It consists of biborate and bicarbonate of sodium, of each, 1 drachm; 
carbolic-acid crystals, 12 grains; glycerin, 2 drachms; water, enough 
to make 8 ounces. Seiler s antiseptic solution is also satisfactory, and 
is easily and quickly made by dissolving one of his tablets in 2 ounces 
of pure water. These solutions dissolve, loosen, and wash out the 
secretions and crusts, so that the diseased membrane itself can be 
reached. Many other formulae will be found in the appendix. 



CHAPTER XIX. 

DISEASES OF THE NASAL CAVITIES. 

Influenza. 

There are two types of this disease. One is an uncomplicated 
catarrhal condition of the respiratory tract prevailing generally dur- 
ing the changes of the seasons from fall to winter and from winter 
to spring, and may appear at any time during the year. The other 
is of an epidemic nature and is known under several names, as fol- 
low: The grip; grippe; epidemic catarrh, or catarrhal fever; blitz 
catarrh; epizootic. Since the treatment of the severer variety will 
include that of the milder, we will consider the subject of the epi- 
demic form. 

Epidemics of influenza date back beyond the Christian era, and 
as early as the year 415 B.C. the Athenian army in Sicily was afflicted 
with this trouble. There is a periodical outbreak of a similar disease, 
occurring twice a year, in January and August, in the Caroline Isl- 
ands, from which nearly all the inhabitants suffer; but this is very 
suggestive of hay fever. In the year 1510 the British Islands were 
visited by a very extensive epidemic of influenza, but up to that time 
no exact records of it were written. Since that period there have 
been more than twenty outbreaks of a severe type, besides many minor 
ones. 

The disease usually is first manifested in the far East, generally 
in some part of Russia, and travels rapidly from east to west. The 
greater the facilities for rapid transit, the faster it invades the western 
countries. It has traveled from near St. Petersburg to Xew York in 
six weeks. It prevails in all climates and attacks all classes of society, 
but infants enjoy partial immunity. While it has been made the butt 
of jest by the uninformed masses and the subject of ridicule by the 
unthinking triflers in medicine, it is more to be feared than small- 
pox or cholera. It cannot be quarantined and controlled by protective 
measures like those diseases, and when it does not kill it blights and 
withers and leaves its deadly sting to blot out one's sight, or hearing, 
or reason, or sows its morbific seeds in other organs to insure its vic- 
tims future maladies. When it first appeared in Paris the effects were 

(■no) 



220 INFLUENZA. 

worse than any of the three epidemics of cholera during the thirty 
years preceding 1884. The influenza epidemic of 1891 in Chicago, 
lasting about six weeks, produced the highest mortality the city had 
ever known. 

Pathology. — The exact nature, cause, and method of origin and 
propagation of this disease are not yet definitely determined. It is 
easier to say what it is not than to say precisely what it is. It is not 
a simple catarrhal affection. It is a specific, infectious, and contagious 
disease. The principal manifestations occur in the mucous membrane 
of the respiratory tract. There are congestion and swelling of this 
membrane in the nose, throat, and pharynx, and sometimes extending 
as far as the bronchial tubes. In certain cases the inflammation in- 
vades the gastro-intestinal canal. F. B. Turck illustrates the im- 
portance of clearing the nose and throat of diseased conditions. He 
demonstrated that the micro-organisms found in diseased stomachs 
were the same as those found in the post-nasal cavities and mouths of 
the same patients. (The Laryngoscope, July, 1896.) 

Various bacteria have been found in the sputa of persons suffering 
from this disease. Staphylococci and streptococci were especially 
abundant, but it is still an open question as to what actually consti- 
tutes the specific infection that gives rise to the attack. Some ob- 
servers believe that the true influenza bacillus has been found, while 
others are of the opposite opinion and suggest that the micro-organ- 
isms found may be the product instead of the cause of the disease. 

It seems reasonable to assume, from the rapidity with which the 
whole organism shows the presence of infection, that it first enters 
the blood. No other theory yet advanced satisfactorily accounts for 
all the phenomena that it presents. 

Etiology. — Epidemic influenza is believed by some to be caused 
by peculiar atmospheric conditions, which would account for its rapid 
extension over a large part of the globe and appearing in widely- 
separated places at nearly the same time. We know that the upper 
strata of the atmosphere, in which volcanic dust is disseminated, will 
carry these particles to the remotest regions of the earth, and that 
dense poisonous gases evolved from subterranean sources may be ex- 
truded into the great ocean of atmosphere about us and prove detri- 
mental to animal life. 

During some invasions meteorological records have shown high 
barometric pressure, drouth, northerly winds, cloudy sky, diminution 
of ozone, and low electrical charge of the air. While the prevailing 



INFLUENZA. 221 

winds have varied greatly in different countries during the same epi- 
demic, extremely dry air has been a constant factor. This unusual 
dryness of the air and earth has led some to believe that the conse- 
quent liberating and floating of the resulting dust in the air and its 
inhalation and irritating effects upon the respiratory passages ac- 
counted for attacks. But a severe epidemic arose in Russia while the 
country was covered deeply with a carpet of snow, and, moreover, the 
respiratory system is not invariably involved. 

It is claimed by some observers that the epidemic does not travel 
faster than man: that obstacles to travel, like mountain-ranges, ob- 
struct its progress: that the most popular means of communication 
between people of different countries form the routes by which the 
disease progresses; and that it first gains foothold in large cities, 
where persons congregate in the greatest numbers: post-offices, fac- 
tories, schools, banks, etc. All these facts point to the harboring and 
conveying of the germs of influenza by human beings. 

Symptomatology. — The variations of the disease as it appears in 
different individuals, and even in the same person, are susceptible of 
classification under three natural divisions of the subject: as it affects 
(1) the nervous system, (2) the alimentary canal, and (3) the respira- 
tory tract, including the Eustachian tube, middle ear, and pneumatic 
cells of the mastoid process. We are especially concerned with the 
latter form. 

It is not common to see all of these forms affect the same patient 
at the same time, but it is not uncommon to see two of them co-exist. 
For example: The great mental depression with extreme prostration 
of the muscular system that first makes its appearance may be quickly 
followed by the gastric and intestinal disturbances that add to the 
exhausted condition already present. We often see the nervous and 
respiratory forms combined, but not the simultaneous invasion of the 
air-passages and alimentary canal. Two of the three forms are some- 
times consecutive to each other. To illustrate: One of our younger 
professors in the Post-graduate Medical School was attacked during 
the epidemic with vomiting and purging and general prostration, from 
which he nearly recovered in five days, when he was seized with sneez- 
ing, running at the nose, sore throat, hoarseness, and mild bronchitis. 

Chilliness and heat may often be marked when the temperature 
rises only one or two degrees, but the rise is often to 103° or 104° 
F. In addition to a sudden sense of great fatigue there often occur 
shooting pains in the head, pain and muscular soreness in the ex- 



222 TREATMENT OF INFLUENZA. 

tremities or abdomen, aching of the back and loins, and in the respira- 
tory form coryza, pharyngitis, and often an invasion of the lower air- 
tract. 

We have observed that patients with an unusual form of middle- 
ear disease begin to present themselves in both private and dispensary 
practice about one week after we become conscious of the presence 
of an epidemic of influenza. They often present this story: "Doctor, 
I was taken a few days ago with a cold in the head, and I had a great 
pain in my ear last night. It broke during the night and ran blood 
and water." They present a picture of acute suffering, anxiety of 
countenance, weakness of the limbs; coated, indented, and tremulous 
tongue; and complain of pain radiating over the corresponding side 
of the head. The mastoid is more often involved than in the simple 
middle-ear inflammation complicating influenza between epidemics. 
The external-ear canal is found to contain bloody serum; the drum- 
head is red, swollen, and bulging; and the tympanum is filled with 
discharge. The hearing is usually much impaired. 

Diagnosis. — As soon as the catarrhal symptoms of the respiratory 
tract make their appearance, the diagnosis is a simple matter. The 
symptoms already enumerated are sufficient to decide the question, 
and the presence of an epidemic will suggest the nature of the com- 
plaint. 

Prognosis. — Robust individuals are able to resist the attacks suffi- 
ciently to recover in a few days or weeks, but persons already debili- 
tated or suffering from diseases of vital organs are prone to succumb 
either during the attacks or as a sequel to them. 

While the general statement may be made that a small percent- 
age of cases die during the attacks, this does not convey any ade- 
quate idea of the actual damage done by an epidemic, because, in 
the first place, such vast numbers of the population fall victims to its 
ravages, and, in the second place, many die, or are made defective, 
as its sequel. 

Treatment. — The patient is put to bed and the bowels relaxed if 
necessary. When the temperature is high it is reduced with anti- 
pyrin or one of its efficient substitutes, and the pain and other dis- 
tressing symptoms are relieved by the coryza tablets containing a com- 
bination of morphia, atropia, and caffeine in the proportion of 1 / 1S 
grain of morphia with 1 / (500 grain of atropia and 1 / 6 grain of caffeine. 
The morphia relieves the pain and nervous irritability, suppresses the 
excessive secretions, and stimulates the circulation; the atropia ele- 



ACUTE EHIXITIS. 223 

vates the tone of the blood-vessels, quickens the pulse, decreases all 
the secretions except the urine, stimulates the respiratory centre, and 
counteracts the constipating effect of the morphia; and the caffeine 
stimulates the nervous centres and the kidneys and diminishes the 
tendency of the morphia to produce nausea. The sneezing and nasal 
discharge cease, the nostrils open up, and the pain disappears. 

We treat the nose and throat with a 3-per-cent. solution of cam- 
phor-menthol in lavolin or henzoinol with the atomizer three or four 
times a day. 

This treatment, with repetition of the doses as the symptoms 
demand, minimizes the suffering, diminishes the intensity of the dis- 
ease, and shortens its course. For rheumatic symptoms salicin or 
salicylate of sodium should be given. Complicating diseases call for 
their appropriate treatment on general principles. 

Acute Ehixitis. 

Synonyms. — Cold in the head; coryza; acute nasal catarrh. 

Pathology. — Simple acute rhinitis is an acute inflammation of 
the mucous membrane of the nasal cavities. The first stage is char- 
acterized by an engorgement of the blood-vessels, not only of the 
mucous membrane, but of the turbinated bodies also. The membrane 
is abnormally red, dry, and swelled. The turgescence of the vessels 
remains during the second stage of the inflammation; but the mem- 
brane becomes bathed in mucus and a copious exudation of serum, 
the strong saline character of which irritates the nostrils and the 
cutaneous surfaces bordering them. Xumerous white blood-corpus- 
cles escape from the vessels into the surrounding tissues; and in- 
creased cell-proliferation in the mucosa announces the third stage. 
Xow the character of the secretions changes from a mixture of serum 
and mucus to a muco-purulent and finally a purulent discharge. It 
is more common to childhood than adult life, and the aged are rarely 
afflicted with it. Coryza forms one of the symptoms of the eruptive 
fevers, and sometimes occasions more distress than the disease it 
accompanies. 

Etiology. — Taking cold is the commonest cause. The impression 
of cold on certain surfaces of the body appears to paralyze the inhibi- 
tory power of the vasomotor nerves controlling the capillary circula- 
tion of the nasal mucous membrane. The most vulnerable surfaces 
are the back of the neck and head and the feet. In speaking f the 
causes of two of the principal symptoms of rhinitis and the manner 



224 ACUTE KHINITIS. 

of their production, Joseph A. White says: "Such phenomena differ 
somewhat in different persons, as I have found by experiments made 
upon myself and others. If I irritate my intranasal tissues it takes 
some time to produce any reflex whatever, but the first to be mani- 
fested is lacrymation on the side irritated, followed by evident swell- 
ing of the corpora cavernosa and by a serous exudation; cough I can- 
not produce at all. On the contrary, if I sit in a warm room with 
my back to an open door or window, I will begin to sneeze almost 
before I am aware of the draught of cooler air. I have observed the 
same effect in others, while, in some, artificial irritation of the nose 
will cause sneezing immediately, and in nearly all such persons con- 
tinuance of the irritation will cause cough." The climatic and me- 
teorological causes are discussed in Chapter I. The nervous tempera- 
ment predisposes to this affection. Wagner (New York Medical Jour- 
nal, October 27, 1894) considers that rhinitic affections are in many 
cases due to the immigration of micro-organisms from the tonsils 
when they are diseased. The uric-acid diathesis predisposes one to 
this disease. 

Symptomatology. — The earliest manifestation of cold in the head 
is a sensation of dryness or irritation in the nostril, prompting one 
to snuff the air as if to dislodge some foreign substance. This gives 
place to itching, tickling, or stinging sensations, followed by parox- 
ysms of sneezing, copious flow of serum and mucus from the nostrils, 
suffusion of the eyes, lacrymation, flushed countenance, and possibly 
sensations of constriction and pain over the eyes in the frontal sinuses, 
and headache. 

The discharge, if continued long, becomes acrid and irritating 
to the nasal opening and upper lip, producing redness, excoriations, 
and cracking of the skin over which it spreads. The efforts of the 
patient to keep the nose and lip dry result in the removal of the 
epidermis to such an extent as to leave a raw-appearing surface. One 
of the most distressing symptoms is the nasal stenosis produced by 
the great swelling of the nasal membrane and turbinate bodies. This 
interferes with swallowing as well as breathing. Eespiration takes 
place entirely through the mouth, and the attempt to swallow liquids 
results in their being forced upward into the nasal space or even into 
the Eustachian tubes. The sense of smell is diminished or absent and 
the voice indicates the seat of the trouble. It has a characteristic 
nasal quality, and the sounds of m and n cannot be produced. The 
disease mav extend to the antrum of Highmore, the frontal sinuses, 



TREATMENT OF ACUTE RHINITIS. 225 

the ethmoid or sphenoid cells, or the Eustachian tubes and middle 
ears. 

Diagnosis. — The group of symptoms described presents so char- 
acteristic a picture that there is no likelihood of confounding this dis- 
ease with any other, but it must not be forgotten that it is a symptom 
of the exanthemata. 

Prognosis. — If the inflammation does not extend to the accessory 
cavities, recovery can be expected in a few days, but may be post- 
poned longer in severe attacks. 

Treatment. — The course pursued in the treatment of influenza, 
varying according to the severity of the attack, can be relied upon 
here. Indeed, this disease can be averted by the use of the coryza 
tablets mentioned for influenza, containing caffeine, morphia, and 
atropia. By giving one of these at the onset of the attack the symp- 
toms subside with as much certainty as can be affirmed of any me- 
dicinal specific. The effect of this remedy lasts several hours, although 
the close is small, and it should be repeated in two, four, or six hours 
if the symptoms begin to reappear. (See page 222.) 

In the uric-acid diathesis (see Chapter XX) lithia should be 
given, and the diet should be carefully regulated (page 250). The 
writer has often aborted attacks by the effervescent lithia prepara- 
tions given in 6- to 10-grain closes two or three times in the twenty- 
four hours for one or more days. 

Prescriptions for the coryza tablets should never be given to 
patients. I have never allowed them to know the composition of the 
tablet, and for this reason no patient has ever contracted a drug habit 
through my carelessness. It would be much better to give the little 
tablets gratuitously than to run any risk whatever of becoming re- 
sponsible for a baneful habit. 

Spraying the nose with a 3-per-cent. solution of camphor-men- 
thol in lavolin or benzoinol (Figs. 129 and 130) affords great relief. 
The physiological effects and uses of this remedy are dwelt upon in 
Chapter XVIII. 

The camphor-menthol pocket-inhaler (Fig. 141) affords much 
relief in mild attacks. Its uses are given in the preceding chapter. 
It affords not only a very refreshing inhalent, but, if employed as soon 
as the first nasal irritation is felt, the symptoms may be checked. 

An important preventive measure is the protection of the body 
from the vicissitudes of the weather. Fabrics of vegetable fibre, such 
as cotton and linen, should not be worn next the skin. Animal fibre, 



226 SIMPLE CHRONIC RHINITIS. 

such as woolen or silk, favors absorption and evaporation of the 
perspiration, keeps the temperature of the surface of the body 
equable, and prevents chilling. Woolen is preferable to silk, except 
in the hottest weather, when thick silk underwear affords more com- 
fort and sufficient protection. 

Simple Chronic Ehinitis. 

Synonyms. — Chronic coryza; blennorrhcea; rhinorrhcea; puru- 
lent catarrh. 

Pathology. — This is a chronic inflammation of the nasal mucous 
membrane, generally consequent upon recurring seizures of acute 
coryza. The membrane is swollen and puffy and the venous sinuses 
are dilated and relaxed (vasoparesis). Extensive infiltration of the- 
interstitial tissue with serum and leucocytes occurs, with a consequent; 
hydrorrhea and degeneration into pus-cells. The mucous glands are 
excited to increased activity, necessitating a frequent resort to the 
handkerchief to prevent dripping from the end of the nose. The mem- 
brane is easily irritated by dust, gases, and sudden changes in the 
weather. 

Etiology. — Exposure to damp and cold and an atmosphere loaded 
with irritating gases or dust act as direct exciting causes. A nervous 
temperament and the. strumous diathesis predispose to the disease. 
Uricacidemia is sometimes an important predisposing cause. - 

Symptomatology. — The increased nasal discharge is the most 
prominent feature, and the end of the nose may become so irritated 
as to give it a red and swollen appearance. The secretions consist of 
mucus and serum, or pus formation takes place to such an extent as 
to fill the nares with a yellow discharge. Its presence provokes fre- 
quent hawking and expectoration. Sneezing is not a constant or fre- 
quent symptom as compared with acute coryza or hay fever. An 
annoying sensation of fullness in the head — especially if the infundib- 
ulum, or passage-way from the frontal sinus to the nose, is obstructed 
— may lead one to suspect involvement of the sinus. 

There is a tendency for this disease to extend to the Eustachian 
tubes, the middle ears, or the nasal ducts, causing impairment of 
hearing and obstruction of the natural tear-passages. The thickening 
of the membrane and the turgescence of the turbinate bodies so con- 
strict the meatuses as to impart a nasal intonation to the speech. 
The walls of the passages are frequently seen to be agglutinated to- 
gether by a viscid, tenacious secretion, or bathed in pus. The mem- 



PLATE III. 



PLATE III. 



Figure 1. — Male, set. 38; hypertrophy of the entire mucous membrane of the 
nasal cavities; relieved by means of bougies and galvanocautery. 

Figure 3. — Rhinoscopic view of above (normal size). 

Figure 2. — Male, set. 30; syphilitic perforation and exostosis of septum; mer- 
curial treatment and mitigated stick locally. 

Figure 4. — Rhinoscopic view showing exostosis of septum in the above (normal 
size) . 

Figure 5. — Female, set. 26; appearance of nasal cavity after loss of septum and 
turbinated bones., and enlargement of the orifice of the antrum through syphilitic 
necrosis. Mercurials and iodides; extraction of necrosed bones with forceps. Potas- 
sium-permanganate washes. 

Figure 7. — Rhinoscopic view of above with mirror facing obliquely from left 
to right (normal size). 

Figure 6. — Female, set. 17; syphilitic perforation of hard and soft palate; mer- 
curials and iodides; mitigated stick locally. 

Figure 8. — View of palate through the mouth (in state of active inflammation). 

Figure 9. — Female, set. 19; mucous polypi; removed with snare; subsequent 
galvanic cauterizations. 

Figure 11.— Anterior view of above (normal size). 

Figure 10.— Female, set. 45; large mucous polypi; removed with snare; sub- 
sequent galvanic cauterizations. 

Figure 12. — Anterior view of above (normal size). 

Figure 13. — Female, set. 30; large fibrous polypus of pharyngeal vault; re- 
moved with electric snare. 

Figure 14. — Male, set. 28; central curvature and exostosis of septum; longi- 
tudinal incision with knife: oakum plugs; exostosis removed with saw. 



[Note. — Represented as seen by gaslight. By daylight the red color appears much 

paler.] 



PLATE III 





TEEATMEXT OF SIMPLE CHEOXIC RHINITIS. 227 

brane is generally redder than the normal, but in the variety in which 
the hydrorrhea is abundant it may appear of a pale-pink tint or even 
livid. 

The secretions may become dry and inspissated to the degree of 
crust formation. These adhering crusts excite a desire to pick at the 
nose until they are removed. This constant source of irritation and 
depriving the septum of its natural protection in the process of repair 
result in perforation in that part of the cartilaginous septum near the 
border of the nares. 

Diagnosis. — To distinguish between this and hypertrophic nasal 
catarrh it is essential to use the probe and cocaine. When the probe 
is pressed upon the turbinals in simple chronic rhinitis it sinks into 
a body comparable to a wet sponge, for the tissues are distended with 
the infiltrated fluids. The depression caused by pressure fills slowly 
like that of a dropsical body. In the hypertrophic variety the probe 
meets with a firm, resisting, fibrous tissue, which possesses greater 
resilience. Cocaine contracts the tissues, in the simple form, until 
they hug the bone, leaving a wide air-space; but not so in the hyper- 
trophic variety. In the latter the surface is uneven, in the former 
smooth. 

Prognosis. — Patients are skeptical as to the curability of nasal 
catarrh. It is so common an affection, especially in the region of the 
Great Lakes, that the inhabitants think that, as a matter of course, 
they must expect to suffer from it. However, with an advantageous 
combination of treatment and hygienic measures, a cure can confi- 
dently be predicted. But one is not warranted in promising no re- 
turn of the trouble under provocative conditions. 

Treatment. — The first requisite to success is cleanliness of the 
nasal cavities. This is best obtained by the use of sprays, — such as 
Dobell's, Seller's, and other solutions, — mentioned in Chapter XVIII. 
These can be injected successfully with the hand-atomizer (Figs. 129 
and 130) if one lack a large air-compressor. Eight pounds' pressure 
is sufficient to thoroughly wash the cavities without any likelihood 
of invading the Eustachian tubes. 

After the membrane is thoroughly cleansed oleaginous sprays 
are indicated to protect the surface, stimulate the absorbents, con- 
tract the blood-vessels, disinfect, and render the mucosa less sensi- 
tive. These remedies are treated of in Chapter XVIII. An effective 
treatment consists in throwing a fine nebula of a 10-per-cent. solution 
of camphor-menthol in lavolin, by means of the vaporizer (Fig. 131), 



228 TREATMENT OF SIMPLE CHRONIC RHINITIS. 

followed by a spray of the following infusion made with lavolin: 
Calendula, 1 per cent.; hamamelis, 2; pinus strobus, 2; lavolin 95. 
Camphor-menthol in the nebula does not bathe the membrane with 
the liquid, but relieves the irritability and stenosis and prepares the 
parts for the coarser spray which will remain in contact with the dis- 
eased surface for many hours. 

Another excellent spray consists of: Camphor-menthol, 3 parts; 
pine-needle oil, 2; eucalpytol, 1; and benzoinol, 94 parts. (See 
appendix.) 

This treatment is best given two or three times a week by the 
surgeon, while the patient pursues a home treatment with a suitable 
atomizer and medicament in order to prolong the effect of each office 
treatment and render it continuous. Cocaine is not mentioned by the 
author as a therapeutic agent, because it is not of such a nature as to 
effect permanent results, and because of the imminent danger of con- 
verting one's patron into a pernicious-drug slave. Cocaine has no 
place in my practice except as an anaesthetic in surgical procedures. 




Fig. 142. — The author's soft-rubber nasal bougie. 

Bougies and dilators of medicated gelatin, hard and soft rubber 
(Fig. 142), and metal are useful in reducing the engorgement of the 
turbinate bodies and overcoming contact and pressure of these bodies 
upon the septum. The bougies adapted in contour and size to each 
individual case are introduced between the turbinals and septum for 
a few minutes at first, beginning with the smaller, and used on the 
same principle as sounds and dilators in other departments of surgery. 

When the engorgement of the vessels of the turbinate bodies pro- 
duces great intumescence of those structures and consequent con- 
striction of the nasal passages that proves unyielding to the methods' 
already mentioned, the cautery is indicated. The electric cautery is 
the most effective, but in its absence chemical cauteries can be sub- 
stituted. A detailed description of the apparatus and methods will 
be found in the treatment of hypertrophic rhinitis. The question of 
proper clothing is considered in the treatment of acute rhinitis. 



CHAPTEE XX. 

DISEASES OF THE NASAL CAVITIES, CONTINUED. 

Hay Fever. 

Synonyms. — Nervous catarrh; nervous coryza; hay asthma; rose 
cold; June cold; July cold; peach cold; summer catarrh; autumnal 
catarrh; pollen poisoning. The Latin equivalents are catarrhus 
sestivus; coryza vasomotoria periodica. French equivalents: catarrhe 
d'ete; catarrhe de foin. German equivalents: Fruhsommer-catarrh; 
Heu-asthma. Italian equivalent: asma dei mietitori. 

Pathology. — In a paper read before the Section on Psychological 
Medicine and Nervous Diseases of the Ninth International Medical 
Congress in Washington in 1887, the author argued the neurotic char- 
acter of this disease. The assembly, which was very large and repre- 
sentative, agreed almost unanimously to the theory that hay fever is 
a neurosis. Only three members who participated in the discussion 
dissented from this view. 

The name "hay fever' 7 is a misnomer. It is employed to desig- 
nate a condition to which numerous other terms have been applied 
with equal fitness. To the array of names already in use, ill-chosen 
because they are misleading, the author had the temerity to add 
another. In a published lecture, delivered in the Chicago Medical 
College in 1885, he proposed the term "nervous catarrh/' Since then 
several authors have adopted this expression. One writer, however, 
calls it nervous coryza; but coryza is from the Greek xopv^a, sig- 
nifying only a running at the nose, while the word catarrh, from 
xarappEG), admits of a much broader application and, with properly 
modifying adjectives, may be used to designate affections of various 
mucous membranes. _ Coryza is a specific term; catarrh is generic, 
and obviously is the more correct one to characterize a disease which 
is not necessarily confined to the nasal cavities. Nervous catarrh is 
so comprehensive a term, and is so tersely suggestive of the pathology 
and symptomatology of certain neurotic derangements, as to be sus- 
ceptible of a much larger usefulness than has been accorded it. To 
illustrate: There is a truly nervous intestinal catarrh which attacks 

(229) 



230 HAY FEVEK. 

and leaves a certain class of individuals' of the nervous temperament 
as suddenly as an attack of hay fever does. The writer has known a 
musician to suffer from severe attacks of diarrhoea just previously to 
his appearance before an audience which he was announced to en- 
tertain. Immediately after his performance all symptoms of intestinal 
disturbance would vanish, only to return again at his next appearance 
in public. We might cite a case of an orator of the evening who was 
similarly afflicted. The nervousness induced by the contemplation of 
addressing his audience would so react on the nervous supply of the 
intestinal tract as to cause sudden and copious diarrhoea. No sooner 
would his oration be finished than all unpleasant symptoms ceased. 
I have known surgeons to be similarly affected. We have nervous 
dyspepsia occasioned by mental emotions. A certain combination of 
objective and subjective causes operating on one individual produces 
morbid phenomena referable to the mucous membrane of the turbi- 
nated bodies, resulting in an attack of hay fever, — nasal nervous ca- 
tarrh. In another, the seat of the resulting manifestations will be in 
the bronchial mucous membrane, eventuating in an attack of asthma, 
— bronchial nervous catarrh. In yet another the intestinal mucous 
coats are the scene of this breaking of a nerve-storm, resulting in 
coj)ious watery discharges, — intestinal nervous catarrh. All these 
are undoubtedly co-ordinate morbid conditions of the nervous sys- 
tem, finding expression in exaggerated and perverted functional ac- 
tivity. 

The pathology of this disease has been evolved from a chaotic 
state, in which it remained from the time of its first description by 
John Bostock, of London, in 1819, until the last decade. Instead of 
looking upon hay fever as a simple congestion or inflammation of the 
Schneiderian membrane, as eminent English authorities have in the 
past, prominent American authors favor the neurotic theory. In this 
connection it is interesting to note that a writer for the London Lancet 
treats of common nasal catarrh as a reflex neurosis, and, in support 
of his position, adduces numerous instances in which purely nerve- 
remedies succeeded in arresting attacks of acute coryza, 

Although this malady is essentially due to an abnormal suscepti- 
bility of nervous tissue, there exists no organic lesion of the nervous 
centres to which the disease is attributable. Being a functional dis- 
turbance, it never destroys life, and no opportunity is afforded the 
neuropathologist to make post-mortem observations. But, if the affec- 
tion be a reflex neurosis, can we hope for microscopy to determine 



HAY FEVER. 231 

with precision the condition of nervous structure which primarily con- 
stitutes the disease? 

The arrangement of the nervous snppl} 7 of the respiratory pas- 
sages is favorable to the existence of reflex nervous phenomena. One 
sympathetic nervous centre, the sphenopalatine ganglion, supplies 
branches to the lining membrane of the nose, pharynx, and Eusta- 
chian tubes. It has a motor, a sensory, and a sympathetic root. It 
communicates with the facial and pneumogastric nerves, thus uniting 
in the closest conection the nose, pharynx, middle ear, larynx, and 
bronchi. Furthermore, the Schneiderian membrane is continuous 
with the lining membrane of the nasal duct and eyelids, the pharynx, 
Eustachian tubes and tympana, the larynx, trachea, and bronchial 
tubes. Ablation of the sphenopalatine ganglion sets up a severe ca- 
tarrhal state of the Schneiderian membrane. A congestion once 
started in this structure may extend with unobstructed facility to the 
contiguous membranes, very like the spreading of an erysipelatous in- 
flammation from one area of the skin to another. But the continuous- 
ness of the membranes throughout these various organs does not sat- 
isfactorily account for all the s}unptoms produced in one part by im- 
pressions upon another. Certainly an inflammation in the throat 
may extend along the Eustachian tube to the tympanum, but there 
is no such reason to account for the sudden transitory tinnitus aurium 
which occurs in some persons immediately upon the ingestion of a 
draught of cold water or the inhalation of tobacco-smoke, or for the 
cough which is occasioned by the contact of instruments with the 
external auditory meatus or with the inferior turbinated body or the 
septum nasi, or for the paroxysm of sneezing produced by irritating 
the scalp. All these symptoms are examples of reflex nervous impulses, 
and these intimate sympathetic relations between various portions of 
the animal economy exhibit themselves with exceptional force in 
patients of a nervous temperament. 

The theory that lesions situated in the nasal cavities may be 
responsible for the existence of common asthma is generally accepted, 
and this is directly in the line of our reasoning, for it argues the reflex 
neurotic character of a disease which possesses close kinship to hay 
fever not only in its etiology, symptomatology, and therapeutics, but 
in the morphology of its secretions. The manner in which exciting- 
causes bring about attacks in hay fever is much the same as in the 
case of asthma. In a hay-fever subject, let brilliant rays of light fall 
upon the retina, or dust impinge upon a sensitive area of mucous 



232 HAY FEVEK. 

membrane, and what occurs? The end-organs of the sensory nerves 
supplying the part affected, being oversensitive to the presence of that 
particular kind of stimulus, are instantly thrown into a state of in- 
tense excitation or irritation. Immediately the impression is flashed 
along the sensory nerves to a nervous centre, — brain or ganglion; 
thence, changed to motor impulse, it is switched back, on the one 
hand, along the vasomotor nerves to the blood-vessels of the seat of 
irritation, causing dilatation, engorgement, swelling, and flux; and, 
on the other hand, along the pneumogastric and sympathetic nerves 
to the muscles concerned in the act of sneezing, and, through ex- 
tensive sympathetic nervous relations, all the respiratory tract and its 
connections may participate in the disturbance and become involved 
in a fully-developed attack of hay asthma, — sneezing, coughing, 
wheezing, nasal flux, expectoration, and lacrymation. 

Thus it appears, from the manner in which paroxysms of hay 
fever are started and developed, that there are three conditions upon 
which the existence of the disease depends: (1) abnormally susceptible 
nerve-centres, (2) hyperesthesia of the peripheral termini of the sen- 
sory nerves, and (3) the presence of one of a large variety of irritating 
agents. Exclude one of these conditions and the paroxysms are pre- 
vented. Allay the susceptibility of the nervous centres by certain 
cerebral sedatives, and an attack is averted or arrested. Anaesthetize 
the nervous supply of the oversensitive areas and the result is the 
same. Eemove the patient beyond the reach of exciting causes and 
he is as comfortable as any mortal. 

Another fact in support of the theory that this is a functional 
disease of the nervous system is its hereditary character. We might 
quote many illustrative cases, but three representative ones will suf- 
fice: In Dr. Morrill Wyman's family there were six sufferers from hay 
fever besides himself. In the family of the Eev. Henry Ward Beecher 
there were two besides himself; and in the family of Chief-Justice 
Shaw there were six members who had different forms of this dis- 
tressing malady. To be sure, heredity alone does not establish a 
neurotic character; but, taken in connection with all the other facts 
in the case, it is a weighty argument in support of the assertion that 
this is a constitutional disorder of a neurotic type. 

Again, the nervous temperament is the predominating one in 
this class of patients, — an argument which needs no elucidation, — 
and the same may be remarked concerning asthmatic sufferers. The 
periodicity of the disease points to nothing if not to its nervous 



HAY FEVER. 233 

nature, for one cannot conceive how the pollen theorists from their 
point of view can reconcile this feature of the complaint with their 
own doctrine. Is it reasonable to assume that the pollen of various 
plants that give rise to attacks in different individuals will he set 
free to float away on their fructifying pilgrimages on exactly the same 
day, and at nearly the same hour, each recurring year, and that they 
will reach the nostrils of sufferers in their varying localities and situa- 
tions and vocations simultaneously year after year? The variations 
that occur in the yearly advance of the seasons preclude this hy- 
pothesis. And, again, the identity of the different forms of the mal- 
ady strengthens the nerve theory, while it weakens the pollen argu- 
ment, for it shows that the disease exists under conditions that are 
the least favorable to the operation of pollen; in fact, where the 
joollen theory is inadmissible, — in the winter and spring. The author 
does not undervalue the importance of pollen as an exciting cause, 
but he wishes to be understood as maintaining that it constitutes only 
one of three factors which render the existence of the disease possible. 

Other arguments that may be briefly mentioned are the sudden- 
ness of the onset and disappearance of attacks, the fact that the most 
potent palliatives are nerve-sedatives, tonics, and stimulants, and that 
mental emotion and physical exertion may prevent or arrest parox- 
ysms. 

The chief argument urged against the nerve theory is that many 
hay-fever patients have diseased nasal cavities. But we may say the 
same of that much larger proportion of our population who have no 
experience with hay fever. That we should find nasal hypertrophies, 
etc., concurrent with hay fever is not surprising in this catarrh-pro- 
ducing climate. Indeed, the diseased turbinated tissue may be a coin- 
cidence or sequence rather than the cause, for it is natural to sup- 
pose that years of constantly recurring attacks of even functional dis- 
turbance of the vasomotor supply of these parts would result in a 
passive hyperemia which would eventuate in proliferation of cells in 
mucous and submucous tissues, and the growth of hypertrophies 
which might serve as a nest for the reception and retention of irri- 
tating agents. But the argument that this condition is responsible 
for hay fever in infants, youths, and even in adults in whom there 
is no evidence of inflammatory changes before or between attacks is 
not tenable. The paroxysms do not so much resemble symptoms of 
an inflammation as they do an irregular and explosive discharge of a 
superfluity of nervous force, — a nerve-storm, if the expression may be 
permitted. 



234 HAY FEVER. 

It lias been hoped that destructive treatment of the sensitive areas 
in the nasal cavities would permanently cure hay fever, and many 
cases have been so treated by American physicians during the last 
twelve years. However, the most sanguine practitioners of this method 
have confessed considerable disappointment at the results. Some 
cases that were supposed to have been cured still suffer, while others 
are benefited. So far as we have been able to obtain definite data, 
they demonstrate that not much more than one-half the number cau- 
terized are claimed to be cured. This points to the fact that it is 
not a simple local inflammatory disease. If it were, the treatment 
should be attended with greater success. For the reasons set forth 
one cannot expect this method to cure all; but, granting that it may 
cure many, the nerve theory would not suffer in the least by the ad- 
mission, for it assumes a pathological condition of the receptive end- 
organs of the nerves as well as of the perceptive nerve-centres. Elimi- 
nate the susceptibility of either the central or peripheral nervous sys- 
tem, and you remove an essential element in the disease, — destroy its 
entity. But what shall we say of that other large proportion of pa- 
tients in whom paroxysms are produced by irritation of the retina, 
the scalp, etc., or by chilling the skin? Are we to be logical and, 
reasoning from analogy, must we destroy the sensitive areas, enucleate 
our patients' eyes, or scalp or skin them? Yet, if you follow the 
reasoning of this school of theorists to its logical conclusion, it will 
lead to this reductio ad absurdum. 

The neurotic theory is supported by the nature of the following 
causes: Electric light and gaslight; overexertion; anxiety; indiges- 
tion; dampness; chills; gases; feathers; perfumes; odors from ani- 
mals; dry, hot, and impure air; various kinds of fruit, etc. It will 
be observed that pollen and dust do not necessarily enter into the 
causative nature of these excitants. 

This theory receives support also from the fact of the excessive 
irritability and nervousness which patients experience just preceding 
and during attacks. The co-ordinate action of muscles is affected, 
and they complain of feeling jerky and ill-tempered for the time. 

In studying this disease it should not be forgotten that the state- 
ments of sufferers relative to the history and phenomena of their 
maladies should be given greater credence than is usually accorded 
the assertions of other classes of patients, inasmuch as they enjoy the 
distinction of being superior to the average in intelligence and cult- 
ure. This is far from being an idle assertion, for it voices the experi- 



HAY FEVER. 235 

ence of the best authorities and is borne out by reference to the list 
of membership of the United States Hay Fever Association. 

TTe cannot consider the treatment of this subject as approaching 
completeness without referring briefly to two other important points. 
Microscopists have examined the nasal and bronchial secretions from 
hay-fever and asthmatic sufferers, with the result, it is claimed, of 
establishing the kinship of the two diseases by demonstrating the 
presence in both of products called "gravel." It is believed that this 
so-called gravel accumulates in the secretions of the respiratory pas- 
sages, and acts as a local irritant in the same manner that any foreign 
body would. Analysis may demonstrate that this gravel consists of 
deposits of urate of sodium. 

The force and analogy apparent in the following facts relating 
to neuroses of the skin serve to emphasize the truth in the nerve 
theory: Intense itching over the surface of the whole body may be 
produced by morbid alterations in the ovaries or uterus, anomalies of 
menstruation, diseases of the kidneys, liver, etc. Xeumann says: 
"There is no doubt that a large proportion of cutaneous diseases de- 
pend upon disorders of the vasomotor nerves which cause certain 
derangements of circulation in the arteries, veins, and cutaneous 
glands. Anaemia and hyperemia of the skin happen from vasomotor 
irregularities, — some from the brain, some from the spinal cord, — 
or from the action of cold, or the electric current, etc." 

Xow, since it is admitted that there are both immediate and re- 
flex functional nervous disorders of the skin, with what show of 
reason can it be denied that there are similar neurotic disturbances of 
that other skin which covers the interior surfaces of the body? The 
latter membrane is more vascular, more delicate, more sensitive, and 
more highly organized than the skin. It possesses susceptibility to 
all agents which affect the skin, and to many others besides. For ex- 
ample, noxious gases, to which the skin is insensible, will irritate the 
mucous lining of the respiratory organs. The same laws that govern 
the action of the vasomotor nerves of the skin also regulate the vaso- 
motor supply of the mucous membranes. If itching and burning of 
the skin are produced by morbid alterations in the ovaries, so is pru- 
ritus urethra? produced by disease of the bladder; pruritus nasi is 
generally accepted as a sign of worms in children; urticaria results 
from irritation of the gastric or intestinal mucous membrane; so may 
asthma arise in the same manner or from an irritant applied to the 
nasal mucous surface; ear-couoh. is occasioned bv contact of instru- 



236 URIC ACID AS A CAUSE OF HAY FEVER. 

ments with the skin of the external auditory canal; and hay-fever 
paroxysms result from irritation of the retina, the upper lip, or the 
scalp, or from chilling the skin. 

All the facts in our possession force us to the conclusion that the 
weight of testimony is in favor of the doctrine that hay fever is a 
reflex functional nervous disease. 

URIC ACID AS A CAUSE OF HAY FEVER. 

Uric acid exists in the blood in the proportion of about one to 
thirty-three of urea in health. "When this proportion is disturbed by 
a relative increase of the uric acid, certain disturbances of a vascular 
and neurotic character arise. The effects of uric acid in producing 
these disturbances have been the subject of an extensive and interest- 
ing series of experiments by Alexander Haig. For years he was a 
sufferer from migraine, and studied in his own person the relation 
of uric acid to the production of attacks of this disease, and the effects 
of anti-uric-acid treatment in subduing attacks, and of diet in pre- 
venting them. I desire at the outset to acknowledge my great in- 
debtedness to this painstaking observer for many of the facts ad- 
duced here. (See "Uric Acid in the Causation of Disease," Haig, 
1896.) 

First, let us consider what the effects of an excess of uric acid 
in the blood are. The disorders of the nervous system that Murchison 
associated with lithsemia are: aching pains in the limbs, lassitude, 
pain in the shoulder, hepatic neuralgia, severe cramps in the legs, 
headache, vertigo and temporary dimness of vision, convulsions, paraly- 
sis, noises in the ears, sleeplessness, depression of spirits, irritability 
of temper, cerebral symptoms, and a typhoid state. 

Haig maintains that the presence of uric acid in excess accounts 
for the exacerbation of pains in rheumatism and gout, and Lever con- 
tends that these diseases are primarily due to the action of this acid 
on the brain, the spinal cord, or the solar plexus of nerves. In persons 
suffering from intense pruritus, uric acid and the urates have been 
found in excess. 

Ebstein believes that uric-acid deposition acts as an exciter of 
inflammation in the tissues in which it is deposited. 

Quinquaud studied the effects of uric acid on the skin. He ad- 
ministered 3 to 6 grains a day to the human subject. The most com- 
mon results were boils and patches resembling eczema, — the dermal 
analogue of coryza. 



URIC ACID AS A CAUSE OF HAY FEVER. 237 

Thomas J. Mays attributes attacks of angina pectoris to "the 
increased formation of uric acid, which is incidental to the gouty 
and rheumatic diathesis." He agrees with Haig in attributing mi- 
graine to the irritating effects of uric acid. 

Conklin details a number of well-marked cases of nervous, men- 
tal, nephritic, and other diseases that support the proposition that 
they are the result of the action of uric acid. 

X. S. Davis and others add the following to the list of manifesta- 
tions of uricacidgemia: Loss of appetite, nausea and vomiting, flatu- 
lent indigestion, diarrhoea, intense itching, asthma, blindness, deaf- 
ness, numbness of the skin and creeping sensations, hyperesthesia and 
pain in the skin, impaired memory, melancholia, delirium, epilepsy,, 
and coma. 

Observe the symptoms of uric-acid irritation that are closely 
allied to paroxysms of nervous catarrh: asthma, intense itching, over- 
sensitiveness and other nervous disturbances of the skin, neuralgia, 
sick headache, irritability of temper, etc. The first three symptoms 
often characterize attacks of nervous catarrh, and highly moral per- 
sons, like the late Henry Ward Beecher, are seized with an almost 
irresistible impulse to accompany their storms of sneezing with a 
shower of profanity. Sick headache sometimes alternates with these 
attacks, and at other times takes the place of them. 

While suffering from migraine Haig found the uric acid increased 
to the proportion of one in twenty or twenty-five of urea, whereas 
before and after attacks he found it as one to forty, and the headache 
was proportioned to the excess of uric acid over the urea, and not to 
the amount of alkali used to bring the uric acid out. The mental 
condition varied directly with the relative amount of uric acid in the 
urine. The excretion of the acid was greatly diminished before the 
attacks, — i.e., during mental exaltation. 

The author has learned, while writing upon this subject, that 
Leflaive analyzed the urine before and during attacks of hay fever,, 
and found uric acid in great quantity just before the attack and half 
that quantity during the attack. Some of this may have been washed 
out of the system through the profuse perspiration that occurs during 
the violent sneezing. 

In 1893 I proposed the uric-acid theory of hay fever in the first 
prize-essay of the United States Hay Fever Association, and at the 
meeting of the American Medical Association the same year I ad- 
vocated the same theory. So far as the writer knew, he was the first 



238 URIC ACID AS A CAUSE OF HAY FEVER. 

to propose this doctrine. In 189-1 it was brought to my attention 
that Shawe Tyrrel, of Toronto, had published a paper in 1892, en- 
titled "A Predisposing Cause of Hay Fever/' advocating the same 
theory. Independently of each other, our studies of the subject forced 
us to arrive at the same conclusions, and I wish to accord Dr. Tyrrel 
full credit for his work. Had I known of it before publishing my 
two essays on the subject, proper reference would have been made to 
his work. 

Haig says: "Uric acid in the blood contracts the arterioles and 
capillaries all over the body, producing the cold surface and extremi- 
ties, raising tension of pulse, and, according to Marcy's law, that pulse- 
rate varies inversely as the arterial tension, slowing the heart. Head- 
ache is a local vascular effect of the uric acid. Excretion of this acid 
may even explain the mental depression and irritability and their re- 
sults in the excess of suicides and murders in July. There is an ex- 
cessive secretion of this acid in the warm months, and a minus excre- 
tion in cold weather. During plus excretion there will be high arterial 
tension, with anaemia of the brain, bad temper, etc. At this time a 
dose of acid would free the brain circulation from the power of the 
uric acid, and produce, as Eoy and Sherrington have shown, an in- 
crease in its size and a free flow of blood in its vessels/' 

Peiper says that alkalescence of the blood is diminished in all 
fevers. Corroborative of this, Haig found, during an attack of in- 
fluenza in 1890, that there was a rise in the acidity of his blood, urine, 
and tissue-fluids, thus driving the uric acid out of these fluids, dimin- 
ishing its excretion, and causing its retention in the body. 

Bertillon says that suicides increased 40 per cent, in France after 
the influenza epidemic. This may be accounted for by the accumula- 
tion of uric acid in the body during the diminished alkalinity of the 
blood, and when the blood regained its normal alkalinity the stored 
acid was taken into the circulation and produced its characteristic 
irritability and depressing effects. 

In health about 5 to 8 grains of uric acid are secreted every 
twenty-four hours, and it is readily soluble in the blood, which is 
slightly alkaline. If there is increased formation of this acid, no 
harm results so long as it is properly eliminated and the ratio between 
it and the urea is not disturbed. 

Haig found that by diminishing the alkalinity of the blood he 
freed it from uric acid, relaxed the arterioles, and relieved headache 
and mental depression. Increasing the alkalinity augmented the acid 



UKIG ACID AS A CAUSE OF HAY FETER. 239 

excretion, contracted the arterioles, slowed the circulation of the blood, 
and caused languor, depression, headache, and, in epileptics, a fit. 
Epilepsy, migraine, spasmodic asthma, etc., are, like neurotic catarrh, 
functional nervous diseases. \That Haig says concerning epilepsy and 
migraine may be affirmed of asthma and nervous catarrh: "They may 
come on early in life, last for years or the whole of life, tend to recur 
at more or less regular intervals, are met with in members of the same 
family, and may afflict one and the same patient, — now a fit, now a 
headache, — alternating or together. Epilepsy and headache, gout 
and rheumatism are very commonly met with in the same family."'" 

Broadbent thinks that the convulsions of epilepsy are brought 
on by the slowing of the circulation and consequent cerebral anaemia, 
in the same way as convulsions after great haemorrhage. As we have 
seen, the effect of an excess of uric acid in the blood-vessels is to 
contract them, which, in the vessels of the brain, produces cerebral 
anaemia. This condition appears to obtain in nervous catarrh, and 
the attacks are relieved by such remedies as nitrite of anryl. etc., which 
relieve anaemia of the brain. 

This uric-acid theory of nervous catarrh is not antagonistic to 
the present status of medical opinion or surgical treatment, but, on 
the contrary, explains questions that were inexplicable before. As 
a tumor or hypertrophied bone may give rise to convulsive seizures 
in epilepsy, and as its removal may be followed by relief when no 
other structural cause exists, so in nervous catarrh, where new growths 
and other lesions of the nasal mucous membrane are present, the at- 
tack may be started by the accumulation and the suddenly setting- 
free of uric acid. This precipitates the paroxysm by its irritant action, 
which finds expression in the group of symptoms characteristic of 
nervous catarrh or asthma, instead of some one of the other allied 
diseases. The particular form of manifestation may be determined 
by the growth, or seat of irritation, located in the nasal cavities. 
Where this is the only determining factor of the nature of the morbid 
symptoms, no other organic disease having resulted from the long- 
standing trouble, the removal of such a peripheral source of irritation 
may give relief from these symptoms, but it may not prevent the 
uricacidaemia from switching off into other kindred lines of disturb- 
ances if it be not corrected. 

The uric-acid theory makes clear the reasons why some persons 
suffer from attacks of nervous coryza under certain favorable condi- 
tions in winter, as well as during the warm months. It also unifies 



24:0 TTKIC ACID AS A CAUSE OF HAY FEYEB. 

all the various forms of hay fever. They are all variations of nervous 
catarrh. 

Patients of this class are sometimes affected more or less by func- 
tional aphasia. Haig's father suffered, from time to time for a large 
part of his life, from this trouble, and in old age had organic aphasia 
with right hemiplegia. The same functional disturbance afflicted 
Haig very markedly, at times of excess of uric acid in the blood, with 
mental depression, lethargy, and headache. The histories of such 
cases are paralleled by the histories of nervous catarrh in many fami- 
lies. 

The periodicity of nervous catarrh has a counterpart in migraine 
that comes once in every seven, ten, fourteen, or thirty days, for years 
or for life. It may last one day or less, rarely two, and is worse in 
the morning. 

In the last published paper of the late A. Beeves Jackson he 
expressed his conviction that various neurasthenic symptoms — sleep- 
lessness, headache, vertigo, neuralgia, vague pelvic symptoms, mus- 
cular twitchings, vasomotor disturbances, etc. — are dependent really 
upon the lithic-acid diathesis. He wrote: "If this fact were duly 
recognized it would remove some of the cases from the list of those 
which are an opprobrium." 

L. C. Gray says: "Influenza, ague, and other fevers store up uric 
acid in the body." There are several causes that determine the man- 
ner in which the irritation produced by an excess of uric acid may 
express itself. These are central, peripheral, and hereditary causes. 
"The structure of the nerve-centres and the distribution of its vessels 
not only determine the kind of disturbances which uricacidaemia will 
produce in any given case, but also explain why one person suffers in 
this way from functional nervous disorders, while another, with about 
as much uric acid in his blood and body, escapes. When the nervous 
system is depressed by fatigue, deficient food, etc., a smaller amount 
of uric acid in the blood will suffice to produce disturbance of function 
than at other times. If uricacidaemia is prevented, the nervous sys- 
tem will not itself originate disturbances. This knowledge of the 
effects of lithaemia gives complete power to produce or remove the 
vascular conditions, and the nervous disorders which are secondary to 
(consequent upon) these conditions, by proper diet and treatment" 
(Haig). The arguments that apply to migraine are just as forceful 
in the case of nervous catarrh. The peripheral causes — neoplasms, 
hypertrophies, etc. — have already been considered. 



UKIG ACID AS A CAUSE OF HAY FEVER. 241 

Heredity is probably the chief factor in determining the direction 
in which the uric-acid diathesis will afflict an individual, whether it 
results in migraine, angina pectoris, asthma, nervous catarrh, or some 
other neurosis; but undoubtedly accidental or acquired conditions 
may act as directing or localizing agents. For example of the latter 
class: a student who is predisposed to such neurosis accidentally in- 
hales the fumes of burning phosphorus in the laboratory, and this 
excites the first attack of his nervous disorder, which naturally, un- 
der these conditions, takes the form of asthma. On the other hand, 
many attacks of severe cold, some injury to the nose, or the develop- 
ment of a polypus may determine the nasal form of neurosis, or nerv- 
ous catarrh. I have such cases in mind. 

We can produce and control attacks of nervous catarrh at will 
by treatment and diet the same as we can migraine. I was first led 
to experiment with an anti-uric-acid treatment of nervous catarrh by 
my endeavors to find a solution to the problem why paroxysms of this 
disease attack sufferers regularly in the morning. These attacks come 
on about the same time, morning after morning, although the pre- 
vious afternoon and evening may have been free from suffering, and 
the night one of restful repose, with no direct access to dust-laden at- 
mosphere from without and no change in the contents of the sleeping- 
apartments. The following facts appear to answer this question: 
The blood is the most strongly alkaline between the small hours of 
the morning and 9 a.m., when it reaches its greatest alkalinity. The 
more alkaline the blood, the more freely soluble is the uric acid. 
Therefore, in the morning hours the blood is the most heavily charged 
with this irritant, and during these hours patients suffer the most 
from angina pectoris, migraine, nervous catarrh, and other functional 
nervous disorders. 

The blood is the most acid during the hours of bodily activity, 
and it reaches its maximum of acidity about midnight. During this 
time there is only a small secretion of uric acid, and the amount cir- 
culating in the blood is minute. As the blood begins to increase in 
alkalinity in the morning it dissolves the uric acid out of the more 
alkaline tissues in which it has been stored, — the liver, spleen, car- 
tilages, joints, and fibrous tissues, — and with the increasing alkalinity 
and solvent properties of the blood it becomes rich in uric acid until 
it produces the drowsiness, heaviness, or other nervous phenomena 
peculiar to any given case. 

Joal found, among 127 cases of hay-fever patients, a family his- 



242 PREDISPOSING and aggravating causes of hay fevee. 

tory pointing to the uric-acid diathesis in 107 cases, and in 67 cases 
among his 71 adult patients the diathesis was marked. Evidences of 
neurasthenia were elicited in 101 of his 127 patients. In 42 of 107 
patients of all ages the nasal mucous membrane appeared to be nor- 
mal (Revue de Larijngologie, Nos. 7 and 8, 1895). 

PREDISPOSING AND AGGRAVATING CAUSES. 

Heredity and the temperaments classed as nervous are, strictly 
speaking, the predisposing causes. Broadly speaking, whatever di- 
minishes the powers of resistance predisposes one to attacks. Most 
foreign substances that are liable to come in contact with the nasal 
mucous membrane will provoke paroxysms, inasmuch as the mere con- 
tact of a polished silver probe will excite sneezing. Dust, pollen, 
infusoria; dry, hot air; cold, damp, or foggy air; smoke, gas, bright 
light from the sun, electric light, gaslight, sunlight reflected from 
snow, etc., are prolific causes. Much may depend on the character of 
the dust, for this is determined by the geological formation of any 
given locality. So wide is the distribution of dust by the varying cur- 
rents of the air that places which would naturally afford immunity 
from this disease may be visited by storms of noxious foreign pollen. 
A sea-voyage is considered a certain cure for an impending attack, 
but even there the enemy may lurk unseen in the folds of the canvas 
or clothing or in the upper currents of the atmosphere. Darwin has 
shown that pollen has been wafted many miles over the Atlantic. 
Showers of pollen have fallen hundreds of miles distant from its na- 
tive soil. Dust may be deposited in curtains, carpets, etc., and be 
retained for indefinite periods before finding lodgment in the respi- 
ratory tract. The upper strata of the air may be laden with pollen, 
as it is at times with volcanic dust,, which may be so dense as to 
darken the sky at great distances from the source of supply. These 
truths illustrate the omnipresent and occult character of the exciting 
causes. 

The greatest suffering occurs from May to October, especially in 
the country, and for the following reasons: At this season the air 
swarms with the fecundating dust of plants and flowers; the dry, hot 
air of the country is not moistened during the day except by occa- 
sional rains; the dry surface-soil affords the winds a never-failing 
supply of dust, and one is not protected from the dazzling brilliancy 
of the sun by tall buildings in the country as he may be while pur- 
suing the vocations of city-life. The streets of cities are deluged with 



EXCITANTS OF HAY FEVER. 243 

water in summer; the dust is laid: the air is cooled and moistened by 
evaporation. Great buildings afford protection from the scorching 
rays of the sun. The denser the population, the less the vegetation 
and the greater the relief to asthmatics and hay-fever patients. 

The irritating effect of dry, hot air causes great activity of the 
muciparous follicles and imposes a heavy burden on the glands to 
pour out sufficient mucus to keep the membrane moist. One must 
avoid dry heat from stoves and furnaces. Much-thumbed books and 
newspapers that are a little musty are exciting causes that I have not 
seen mentioned. 



CHAPTER XXI. 
DISEASES OF THE NASAL CAVITIES, CONTINUED. 

Hay Fever, Concluded. 

Symptomatology. — A reciprocal relation exists between the capil- 
lary circulation of the skin and that of the internal organs, but more 
especially affecting the mucous membrane lining the air-passages. Let 
the surface of a hay-fever patient become chilled, the skin anaemic, 
the perspiration checked, and immediately there follow a correspond- 
ing hyperaemia of the mucous membrane of the respiratory passages, 
an increased activity of the muciparous follicles, exquisite tickling and 
painful itching in the nose and pharynx, succeeded by violent sneez- 
ing, profuse discharge of nasal mucus, suffused and tear-bedimmed 
eyes, photophobia, a rush of blood to the head and face, severe head- 
ache, complete occlusion of the nostrils, nervous exhaustion, and such 
a desperate shaking up of the whole being as is comparable to a 
wrecked vessel in a terrific storm. But in this violent agitation of 
the body I have discerned a blessing in disguise, for it restores the 
balance of circulation to the skin, the temperature rises, the sudorifer- 
ous glands resume their activity, and the skin is again bathed in per- 
spiration. At this juncture the vicarious suffering of the respiratory 
surface is relieved and the normal equipoise of functional activity 
ensues. In one who suffers from the asthmatic form of hay fever, to 
the symptoms already enumerated should be added the characteristic 
symptoms of asthma proper. These alone make one's lot hard enough, 
but when added to the so-called "aristocratic" disease they present a 
highly-colored picture of the refinement of torture. 

The sneezing is often so violent and continuous that the patient 
is scarcely able to catch sufficient breath to properly oxygenate the 
blood. The hydrorrhea is so profuse as to saturate many handker- 
chiefs, — a dozen or a score in a day in severe cases. One peculiar 
symptom I have observed, but have never seen mentioned by other 
writers, is: the instant some patients begin to sneeze, they also swell 
up so that the clothes about the abdomen and waist must immediately 
be loosened to afford relief from the constriction. 

These attacks come on at precisely the same time and last the 

(244) 



HAY FEVER, SYMPTOMATOLOGY. 245 

same length of time at each recurring season. A sudden mental ex- 
citement may prevent an impending paroxysm or abbreviate one after 
its onset. The attack is as instantaneous in its invasion as asthma, 
striking one at any moment of day or night, awaking one from sound 
slumber, or taking one unawares during the pleasant engagements of 
the day, and leaving as quickly and mysteriously as it came. 

Some functional nervous diseases are transmutable, one into 
another. The author has witnessed cerebral hyperemia decline and 
disappear as hay fever superseded it, and after several years' duration 
the hay fever has, in turn, been displaced by asthma, as spasmodic 
and characteristic in its nature as the hay fever itself. Simple asthma 
may not only supplant, but may complicate it, constituting hay asthma 
proper. 

Inspection of the nasal cavities during attacks reveals the 
turbinated bodies enormously swollen and water-soaked, the mucous 
membrane very vascular, and the passages completely closed. The 
membrane is exquisitely sensitive and often painful. In sleep it 
is necessary to breathe through the mouth, which occasions distress- 
ing dryness of the throat. The breath must be held while masticating 
or swallowing food, and with every act of deglutition the air is forced 
into the Eustachian tubes, and even particles of food seem to take the 
same course. 

In the intervals between the seasons of suffering, and even be- 
tween paroxysms from day to day, the nasal membrane may present 
no unusual appearance. Indeed, just before a seizure the nostrils may 
seem more patulous than normal, affording perfect freedom of res- 
piration. In some cases we have been unable to find any appearances 
whatever of a diseased condition between attacks. Others have the 
same hypertrophies that are common to other patients. 

There are considerable variations in the experiences of hay-fever 
sufferers, both with respect to their symptoms and the times of their 
attacks. It is very common for them to awaken in the morning feel- 
ing perfectly well, with the nasal passages comfortable and free; but 
the moment they arise and touch their bare feet to the cool floor, or 
feel the air strike the lower extremities or body, or even before rising, 
a few minutes of wakefulness are followed by sensations of dryness and 
irritation in the nose and miserable paroxysms of sneezing, as though 
they had taken a severe cold. The attack may last for a few minutes 
only, or until the morning meal with coffee, when all the symptoms 
subside. The attacks may reappear at intervals during the day, with 



246 ABOKTIVE TREATMENT OF HAY FEVER. 

or without a feeling of rawness of the nasal membrane between the 
spasms of sneezing. 

Unlike the occasional sneeze of an individual who is not subject 
to hay fever, the act of sneezing is unaccompanied by any sense of 
pleasure or satisfaction. It is positively distressing, and makes the 
sufferer wretched. He is harassed by a consciousness of impatience 
and irritability of temper; his muscles act in a jerky, inco-ordinate 
way, causing him to drop things or knock them together; he must 
always be on the alert to avoid or escape those excitants of suffering 
that beset his path on every hand. 

The time these attacks usually come on is the 18th of August, 
but may vary from the 15th to the 20th in different individuals, 
although there is little, if any, variation in the case of any given 
patient. The season of suffering generally lasts until a severe frost 
occurs in September or October, when the season ends, and the refu- 
gees who have fled to the mountains or lakes of immune regions return 
to their homes to enjoy life until the following summer. In a small 
proportion of cases the attacks are more or less perennial. Exposure 
to sunlight reflected from snow, or to close, hot, impure, or dusty air 
in winter, will result in suffering. Some are attacked in June or in 
July, when certain grasses ripen and the haying season is at hand. 
The presence of roses or certain other flowers may provoke sneezing 
at any season. 

Diagnosis. — Considering the characteristics and the description 
given, the matter of diagnosis is so simple as to require no further 
mention. 

Prognosis. — Hay fever is not dangerous to life, although it causes 
serious suffering and incapacitates one for business while it lasts. It 
does not tend to disappear of itself permanently, but is amenable to 
treatment. 

Abortive Treatment. — With the uric-acid phenomena in mind, I 
attempted to break up the morning attacks of sneezing and nasal 
stenosis by doses of acid at bed-time and on first awakening in the 
morning. The experiment was a success. A series of wretched morn- 
ings was followed by freedom of respiration and a sense of well-being 
that seemed like a physical millennium. After this result of pre- 
venting the morning increase in the alkalinity of the blood, in order 
to prove the correctness of his deductions, the writer used an alka- 
line treatment, and was both delighted and disgusted with the re- 
sults. The old enemy raged again, but here was clinical proof of his 



ABORTIVE TREATMENT OF HAY EEVER. 247 

first proposition. These experiments have been successfully repeated 
until I am satisfied of the correctness of these conclusions. 

The first acid used for these experiments was the dilute sul- 
phuric acid in doses of 20 or 30 drops in water, but, on account of the 
griping pains and diarrhoea that it produced in the early morning, 
we ay ere obliged to substitute another. It occurred to me to try Hors- 
ford's acid phosphate that I had used for other purposes for some 
years, on the recommendation of the late Professor Jewell. 

We used teaspoonful doses of this acid without any ill-effects, 
and with the result of giving complete immunity from suffering. 
One or two teaspoonfuls in a glass of water at bed-time and on first 
awakening in the morning were sufficient to break up the habit en- 
tirely. In a few days, after the symptoms ceased to appear in the 
morning, this dose was omitted. The night dose was continued until 
the habit seemed to be entirely broken up. If any nasal irritation 
reappeared, a dose or two would dispel it. By adding sugar to this 
acidulated drink it makes an agreeable lemonade, but it is better to 
avoid the sugar, and as much as possible all other uric-acid producing 
substances. 

While the author has depended on the mineral acids to keep 
down the morning alkalinity of the blood, Bence Jones claims that 
citric acid (lemonade) will accomplish the same result. We have 
made it a point to have the morning dose well diluted with Yvater, 
for the purpose of starting perspiration, for we have observed that 
as soon as a patient has sneezed violently enough to produce free 
sweating the symptoms either decreased or disappeared. The sweat- 
ing carries off uric acid and helps to free the blood. 

I am aYY^are of the differences of opinion that exist concerning 
the influence of an excess of dilute phosphoric acid on the elimi- 
nation of uric acid, the effects of acid on the tubules of the kidneys, 
and the relation of a meat-and-vegetable diet to the formation of 
uric acid. We are careful to use only so much acid as is required 
to prevent the maximum of alkalinity from occurring. The acid is 
used not with the expectation of eliminating, but of clearing the blood 
of uric acid, for the purpose of preventing attacks during the season 
of suffering. If the overwrought nerves are relieved of this source 
of irritation, they are much less likely to respond to other excitant-: 
and, if the morbidly-susceptible condition of the nervous centres is 
due to the action of the uric acid, its oversensitiveness to all excitants 
may be relieved by correcting' the uricacidamiia. After relieving- the 



248 ABORTIVE TREATMENT OF HAY FEVER. 

suffering with the acid phosphate I have produced it again by neu- 
tralizing the acid with an excess of bicarbonate of sodium and em- 
ploying the usual doses. This converted the acid into a ready solvent 
of uric acid, flooded the blood With it, and produced the attacks. 
In turn, I have followed this up with the acid, relieved all the ca- 
tarrhal symptoms by precipitating the uric acid from the blood into 
the tissues, and produced the characteristic gouty pains. Again, by 
substituting drachm doses of phosphate of sodium for the acid I have 
precipitated all the symptoms of a severe nasal catarrh. 

Some other remedies produce effects parallel to the acid treat- 
ment. Nitroglycerin, nitrite of sodium, nitrite of amyl, antipyrin, 
etc., have a similar effect. Opium raises the acidity of urine, dimin- 
ishes the alkalinity of the blood, and reduces the amount of uric 
acid. It relaxes the arterioles and improves the circulation of the 
brain. Iron and lead have a similar effect. Mercury reduces the ex- 
cretion of uric acid, reduces tension of pulse, and produces diuresis. 
If opium is employed, its ill effects should be prevented by follow- 
ing up its use with salicylate of soda for a few days to free the system 
of uric acid. Quinine, so generally used, is contra-indicated, for, 
according to Quain, it brings uric acid into the blood. 

There is one remedy that has proved, in my hands, invariably 
unfailing in giving relief, especially when given at the beginning of 
an attack of nervous catarrh or common colds. It is for temporary 
use only, like the acid treatment. . The author has employed it for 
the last sixteen years or more, but in this case it is, like old wine, 
the better for age. This is a combination of atropia and morphia, 
in the proportion of 1 part of atropia to 50 of morphia. The ordi- 
nary adult dose is from 1 / 16 to 1 / 8 grain of this mixture, according 
to the severity of the attack. It may be repeated in an hour or two, 
if the first dose does not entirely relieve the sneezing, running at the 
nose, and stenosis. I do not believe it has ever failed to stop an attack 
when properly adapted to the case. No person has ever acquired the 
drug habit through my prescribing it. I never write a prescription 
for it nor allow a patient to know the composition of the remedy, — 
not for mercenary purposes, for it is more often given away than 
charged for, but in order to obviate the possibility of being responsible 
for a drug habit. The morphia clears the blood of uric acid, dimin- 
ishes the nervous irritability, suppresses oversecretion from the mu- 
ciparous glands, and stimulates the circulation and activity of the 
nervous centres, while the atropia elevates the tone of the blood- 



TREATMENT OF HAY FEVER. 249 

vessels, quickens the pulse, decreases all the secretions except the 
urine, sustains bodily temperature, stimulates the respiratory centre, 
counteracts the constipating effects of the morphia, and acts as an 
antispasmodic. Caffeine, 1 / 6 grain, may be added to this dose to 
stimulate the nervous centres and kidneys. 

Local Self-treatment. — The most useful self-treatment probably 
is (1) the use of a convenient pocket-inhaler (Fig. 141) that I have 
devised for patients who take cold easily. It is called the "camenthol 
inhaler." It can be used in an inconspicuous and expeditious man- 
ner in public places, where it would be impracticable to combat a 
sudden seizure with other and slower measures. Several gentle, pro- 
longed inhalations should be taken through one nostril while the 
opposite one is closed, until the irritation is relieved. The breath 
should not be allowed to pass back through the inhaler, but through 
the mouth instead. The camphor-menthol does not become irri- 
tating to the membrane, like menthol alone, after having been used 
a considerable time. It is blander and more soothing than the men- 
thol crystals, iodine, or carbolic acid. When the throat is involved, 
it can be inhaled through the mouth for self-treatment. .2. For home 
treatment, morning and night, we usually prescribe a solution of cam- 
phor-menthol in lavolin, to be sprayed into the nostrils and throat. 
The 1- and 3-per-cent. solutions are the most satisfactory. It is best 
to begin with the weaker, and increase gradually to the 3-per-cent. 
solution. 

Joseph A. White applies a much stronger solution than the last 
named in the asthmatic type. He first applies a 1-per-cent. solution 
of cocaine, and follows this with camphor-menthol, of which he gives 
the following formula (Burnett, vol. ii, p. 126): Menthol, gum cam- 
phor, of each, gr. xxx; liquid cosmolin, §j. (The quantity of liquid 
cosmolin was printed as a drachm, but an ounce was probably in- 
tended. However, this is about four times as strong as this very sensi- 
tive class of patients will generally tolerate with equanimity unless 
preceded by cocaine, and liquid cosmolin is not as bland a vehicle as 
lavolin, benzoinol, or albolene, all of which have been deprived of the 
irritating properties characteristic of cosmolin when applied to the 
nasal mucous membrane. 

Preventive Treatment. — The treatment to eliminate uric acid 
cannot be undertaken to advantage during the season of attacks, ex- 
cept so far as relates to diet and the use of lithia. Haig does not 
believe that excessive uric-acid formation takes place: but, from a 



250 PREVENTIVE TREATMENT OF HAY FEVER. 

considerable study of this subject, one is forced to the conclusion that 
an excess of uric acid in the system is not due alone to continued re- 
tention and storage of the small normal overflow by the renal vein, 
but to an increased formation also. In a conversation with N. S. 
Davis, that eminent authority corroborated the latter view. It fol- 
lows, then, that it is necessary to reduce as much as possible the use 
of those foods that increase the actual formation of uric acid, such 
as meats, sweets, beer, wine, etc., and limit the diet largely to fruits, 
vegetables, milk, etc. 

Exercise also aids in the excretion of uric acid, although there 
may be an actual increase in the amount of acid. Lange treats peri- 
odical mental depression successfully by reducing the amount of food 
and by systematic exercise. 

A diet of milk with occasional very small quantities of egg and 
fish, with no other animal food, will prevent suffering from sick head- 
ache entirely, without medicinal treatment. With this diet the nat- 
ural ratio between uric acid and urea — 1 to 33 — is maintained. Haig 
claims that, by a uric-acid-producing diet, one can store up in the 
body several ounces of uric acid in a few years, or, by a correct diet, 
not as many grains. He has been on such a diet over eight years with 
very seldom a headache. By eating meat and drinking wine two or 
three days in any single week, he is sure to bring on the migraine. 

A course of salicylate, salicin, lithium, etc., will remove the excess 
of uric acid. If an alkali is given it is likely to produce uricacidaemia 
and precipitate an attack of the trouble we are endeavoring to pre- 
vent. For an attack, then, a dose of acid should be given to free the 
blood of uric acid; then the salicylate of sodium should be given for 
two or three days or longer, to sweep it out of the body; but the 
salicylate should not be given during the attack, for it may aggravate 
the symptoms. For a fortnight or a month, perhaps longer, preceding 
the regular season of attacks of nervous catarrh, from 2 to 6 grains 
of the salicylate should be given every day or two, in order to get 
and keep the quantity of the acid in the body down to the normal 
amount. The copious use of the stronger lithia-waters is advanta- 
geous, also. Warner's 3-grain tablets of effervescing citrate of lithia are 
excellent, and the same may be said of alkalithia and the effervescent 
citrate of lithia, soda, and potash. The writer now depends mostly 
upon lithia as a preventive remedy. 

This treatment, combined with proper diet, should be successful, 
provided that there is no organic disease of the structures, central 



HAY FEVER, MEDICAL OPINIONS. '251 

or peripheral. Any organic disease — hypertrophy, polypus, etc. — must 
receive such attention as to secure the harmonious co-ordination of 
their functions, for this treatment is directed against uricacidaemia 
only, as a cause of suffering; hut it should not he forgotten that there 
are other causes that may operate to produce attacks, just as in the 
case of spasmodic asthma arising from bronchitis, irritating gases, and 
other excitants. 

In this connection it is worth while to note the apparent effect 
of an operation on the ear in relation to hay fever. In June, 1897, 
I removed an aural polypus and the ossicles, and curetted granula- 
tions of the middle ear under a 20-per-cent. cocaine anaesthesia in 
a case of long-standing chronic suppuration. The patient, who was 
an educator, was a hay-fever sufferer. Heretofore the attacks had 
come on in June and lasted until the frosts of fall. In November,. 
1897, the patient, who lives a considerable distance from the city, 
called and informed me that the operation had relieved her from hay 
fever, for she had escaped it entirely the past summer. The sup- 
puration ceased; but whether the freedom from hay fever was a con- 
sequence or a coincidence is a debatable question. 

The author is of the opinion that, with this new theory, im- 
proved therapeutics, and proper diet of this disease, the medical pro- 
fession need no longer say to ha} T -fever patients, in a patronizing way, 
"Suffer little children, for of such is the kingdom of heaven/ 7 But 
we must recognize and combat the uric-acid diathesis if we would 
bring comfort to these patients and obliterate a stigma that dims the 
lustre of our great art. 

MEDICAL OPIXIOXS. 

YTe have written to a large number of specialists and writers on 
this subject to obtain their latest views and treatment. There were 
some whose recent publications made it unnecesary to write, and others 
who were inaccessible; so we have in such cases searched the literature 
and endeavored to present a fair and impartial account of the present 
status of medical opinion on the nature and treatment of hay fever. 
From some articles it is impossible to gather any definite knowledge 
of the opinions of the writers on the nature of the disease; we have 
stricken out much for that reason, but have, in every case presented, 
striven to give a natural and unbiased interpretation of the author's 
views. The methods of treatment often indicated these. The opinion 
of each writer on the pathology, whether he believes it to be a neu- 



252 HAY FEYEE, MEDICAL OPINIONS. 

rotic or local affection, is indicated by a single word following his 
name, — neurosis or local. 

E. L. Shurly. Neurosis. "I am very glad that you will present the 
subject of the treatment of hay fever. It is a very important one, and does 
not receive the intellectual attention which it deserves. It is my belief that 
some cases can be relieved by counter-irritation in almost any part of the body, 
as well as in the nasal passages. I also believe that its purely nasal origin is 
overestimated. I have found snuff of daturine with starch sometimes more 
effective than the galvano-cautery." He uses tincture of iodine, etc., over the 
neck and chest, as recommended by Faulkner. If there are new growths he 
removes them. 

W. E. Casselberry. Neurosis. "I believe hay fever to be amenable to 
thorough surgical treatment, establishing a complete cure in a minority of 
cases only, — those particularly which present gross deformities of the septum 
and the turbinates, and polypi. In the large majority the condition can be 
materially mitigated, the degree of improvement being in accordance (1) with 
the degree of structural disease present in the nose and (2) with the thorough- 
ness of the treatment. A small minority are not amenable to surgical treat- 
ment. They include the highly-neurotic individuals in whose noses, between 
the paroxysms, little or no structural change is apparent. Much can be ac- 
complished toward palliation by both systemic and local medicinal treatment. 
But in my experience medicinal treatment is nearly, if not quite, powerless to 
effect a permanent cure. Such, however, may take place in the course of years, 
perhaps, assisted by supportive and tonic treatment, as the individual's gen- 
eral health improves and the neurotic element lessens. Of local palliative 
remedies, cocaine is probably the most powerful and at the same time the most 
dangerous remedy. Its use and sale should be regulated by law." 

C. H. Knight. Neurosis. Destroys all enlargements. "When it is im- 
possible to define a distinct abnormality, the nasal membrane throughout 
being sensitive and irritable, good results seem to me to follow painting the 
mucous membrane with a solution of perchloride of mercury, muriate of 
quinine, and glycerite of carbolic acid. Of course, general treatment is always 
essential. I must confess that my proportion of cures is small. I feel quite 
pleased if I succeed in mitigating the severity of the symptoms and lessening 
their duration, etc." 

W. C. Glasgow. Neurosis. "Surgical treatment has given little or no 
permanent relief. Symptomatic treatment will ameliorate the symptoms and 
keep the patients in comparative comfort during attacks. The constitutional 
treatment with potassium iodide, belladonna, antipyrin, etc., lessens the dis- 
turbance and sometimes controls it." 

Jonathan Wright. Neurosis. "I have seen several cases with no ap- 
preciable intranasal lesion except the acute condition during the attack. I 
have operated a few times for intranasal lesions of various kinds. All were 
improved somewhat, — some markedly, some slightly. My impression is that the 
relief in these cases is too limited to make it of value." 

R. W. Seiss. Neurosis. "Operations in the nose should be resorted to 



HAY FEVER, MEDICAL OPINIONS. 253 

cautiously, and only when absolutely necessary.'' He recommends strychnine 
and bromides internally, and benzoate of sodium, 10 to 20 grains to the ounce, 
or menthol, 10 to 30 grains, for a spray. 

E. J. Kuh. Neurosis. A sufferer from hay asthma. He found the most 
relief from the following spray: Camphor, 1 / 2 part; menthol, 1 part; creasote, 
1; oil of eucalyptus, 2; oil of pine-needles, 2; albolene, 93 1 / 2 parts. 

J. 0. Eoe. Local. He believes that there is always a diseased condition 
of the nose causing hay fever. These diseased tissues must be removed or 
destroyed. He denies the neurotic character of the disease. He says: "Irrita- 
tion reflected from other situations to the nasal chambers is not hay fever." 

F. H. Boswoeth. Neurosis. He believes that intranasal surgery affords 
permanent relief. This method is clear in its indications, easy of accomplish- 
ment, and promises not only more immediate, but more permanent, relief than 
any other method. He believes that hay fever and spasmodic asthma are patho- 
logically identical. 

J. N. Mackenzie. Neurosis. Better results were obtained from constitu- 
tional than from local treatment. He gives zinc, nux vomica, quinine, and 
arsenic. 

W. H. Daly. Local. He thinks it is simply a deformity in the nose, and' 
that a large proportion of cases can be cured by surgical operations. 

J. Solis-Cohen. Neurosis. Any local nasal trouble may be simply inci- 
dental. He prescribes tonic treatment and restricts the use of meat. 

H. Geadle. Neurosis. He removes any nasal growths. 

Kitchen, of Xew York. Local. He believes it is due to the membrane 
being deficient in the epithelial covering, etc., that calls for local remedies. 

B. O. Kinneae. Neurosis. He believes it to be due to irritation of the 
gray matter composing the centres of the fifth, glossopharyngeal, the facial 
nerves, and some of the pneumogastric. He found that treatment addressed 
to this condition was successful. He used the well-known ice-bags of J. Chap- 
man, of Paris, along the spine between the shoulders, from the fourth cervical 
to the third dorsal vertebra, to dilate the arterioles of the whole body, thus 
evenly distributing the circulation and withdrawing the blood from the con- 
gested centres. The applications lasted from sixty to ninety minutes, one to 
three times a day. 

E. F. Ingals. Neurosis. About 40 to 50 per cent, of cases may be cured 
by cauterization. He gives tonics and uses cocaine locally. 

M. R. Beown. Neurosis. The supersensitive areas should be destroyed 
with the cautery. Atropine, 1 / 100 grain, once or twice daily or a 4-per-cent, 
solution of cocaine locally may give temporary relief. 

H. H. Curtis. Neurosis. He sears the enlarged tissues with chromic acid 
in preference to all other escharotics. 

C E. de M. Sajous. Neurosis. He believes that if cauterization fail to 
cure, it is because it is not carried deeply enough. He uses glacial acetic acid 
or nitric acid, and he gives strychnine and coca-wine after meals. 

William Cheatham, of Louisville. Neurosis. He praises antipyrin in 
10 to 30 grains; also acetanilid, 4 to 6 grains a day. 

T. M. Haedie. Neurosis. He believes that operations will benefit a large 
proportion, but constitutional treatment is necessary in most instances. 



254 HAY FEVER, MEDICAL OPINIONS. 

Beverly Robinson. Neurosis. Soothing applications and constitutional 
medication. He advises against surgical interference except when there are 
positively-diseased growths. 

I. Gluck. Local. He believes the nervous element to be a result, instead 
of the cause, of the disease. He uses a 10-per-cent. solution of atropine after 
anaesthetizing with cocaine-phenol. He gives aconitine every hour or two, 
affording relief and aborting attacks in from two to five days. 

Carl Seiler. Neurosis. He uses sprays of cocaine and plugs of cotton 
saturated with it. A sponge worn in the nose to filter the air is recommended. 
Quinine in large doses is advised and tonics and atropine for the fever. In the 
later stages iodide and bromide of sodium are given. Morphine hypodermic- 
ally is advised. All enlargements should be removed; he gives dilute phos- 
phoric acid, 30 drops a day. 

De Lamalleree. Neurosis. He believes it is a neurosis of nasal origin, 
and claims to subdue morbid sensitiveness of the membrane by douches of car- 
bonic-acid gases locally for fifteen minutes at a time, three times a day. 

Sir Andrew Clark. Neurosis. He resorts to constitutional remedies 
and applies to the nostril with a camel's hair pencil this mixture: 1 ounce 
each of glycerin and carbolic acid, 1 drachm of quinine, and V2000 part of the 
perchloride of mercury. Heat must be used to dissolve the quinine. 

P. McBride. Neurosis. He treats it as a nervous disease, and if this fail 
he uses cocaine and the galvanocautery. He deprecates indiscriminate cauter- 
ization, however. 

D. B. Lees. Neurosis. He claims to abort it with bromide and bella- 
donna. 

John North. Neurosis. Employs anti-uric-acid treatment, and removes 
hypertrophies, with satisfactory results. 

Gouguenheim. Neurosis. He uses nervines, and cocaine locally. 

The author operates with the electrocautery or by other methods when 
there are indications for such measures. 



PLATE IV. 



PLATE IV. 



Figure 1. — Male, get. 21; anterior view of extensive osteo-enchondroma of sep- 
tum, occluding completely left nasal cavity; mass reduced with dental engine. 

Figure 2. — Lateral view of above. 

Figure 3. — Posterior view of asymmetrical nasal cavities of above case; com- 
plete stenosis of the left naris. 

Figure 4. — Male, get. 44; anterior view of deviation of septum to right, causing 
partial occlusion of cavity. 

Figure 5. — Lateral view of above, showing concavity of septum anteriorly and 
a convexity posteriorly, due to abnormal thickness of the septum. 

Figure 6.- — Posterior view of above, showing the thickened septum pressing on 
left middle and inferior turbinated bodies; causing asthma. Thickness reduced with 
surgical engine, passing burr under the mucous membrane; asthma relieved. 

Figure 7. — Male, get. 48; relaxation of soft palate, causing symptoms of elon- 
gated uvula; astringents found useless; amputation of uvula. 

Figure 8. — Female, get. 22; elongation of uvula, causing cough, expectoration, 
etc., and general symptoms of phthisis; amputation; complete relief. 

Figure 9.— Female, get. 27; position of mouth in forcible separation of jaws 
during tonsillitis; further examination impossible; diagnosis established by char- 
acter of pain, color of tongue, odor of breath, and dysphagia. 

Figure 10. — Male, get. 28; hypertrophy of the tonsils; amputation with ton- 
sillotome. 

Figure 11. — Appearance of tonsils in above case during an attack of tonsillitis. 



[Note. — Eepresented as seen by gaslight. By daylight the red color appears much 

paler.] 



PLATE IV. 




CHAPTEE XXII. 
DISEASES OF THE XASAL CAVITIES, CONTINUED. 

Hypebtbophic Rhinitis. 

Pathology. — In this form of nasal catarrh there is not only a 
thickening of the mncoiis membrane, but also an increase of connec- 
tive-tissue formation in the submucous layer, or corpora cavernosa. 




Fig. 143. — Xasal synechia. Point of probe is inserted between the inferior 

turbinated body and the projection of the septum at the point 

of their union. (Author's specimen.) 

'The venous sinuses, having passed through the stage of vasoparesis, 
have now become permanently dilated. The newly-formed fibrous 
tissue prevents their contraction and maintains them rigidly dilated 

(255) 



256 



HYPERTROPHIC EHIXITIS. 




Fig. 144. 



-Posterior view of osseous bridge shown in Fig. 143. 
(Author's specimen.) 




Fig. 145. — Transverse vertical section through the vault of the pharym 

and Eustachian tubes. 1, posterior border of the vomer; 2, 

Eustachian tube; 3, inferior turbinated body. 



HYEEETEOElilC RHINITIS. 



2b: 



until pressure upon their walls by contraction of this tissue, the pres- 
ence of leucocytes, or the formation of connective-tissue septa and 
thrombi within the sinuses finally obliterates them. 

During the hypertrophic stage there is increased vascularity of 
the turbinate and of the septum. The most frequent situations of 
thickening of the membrane and tissues beneath are the posterior ends 
of the turbinate bodies (Plate V and Figs. 145 to 148). Depressions 
and spurs of the septum nasi, ecchondroses and exostoses, and sig- 
moid deflections resembling corrugations are frequent accompani- 




Fig. 146. — Transverse vertical section through the posterior nares. 1, sphe- 
noid antra; 2, posterior end. of the inferior turbinated body. 



rnents (Plate IV). Occasionally adhesion occurs between the septum 
and turbinate, forming a bridge, or synechia (Figs. 143 and 144). 

Etiology. — This is a sequel of simple chronic rhinitis. 

Symptomatology. — The obstruction to the free passage of air 
through the nose, by great thickening and deformities of the turbinate 
and the septum, causes partial or complete mouth-breathing. Patients 
complain that they take cold easily and that when lying on one side 
the lower nostril closes. The latter symptom occurs in consequence 
of the blood gravitating to the lower turbinate and causing them to 
swell. A slight exposure results in stenosis of both nostrils, and as 

17 



258 



HYPEKTKOPHIC RHINITIS. 




Fig. 147. — Transverse vertical section through the orbits, nasal fossse, 
and maxillary antra. 1, ethmoid cells; 2, superior turbinated body; 3, 
middle turbinated body; 4, antrum of Highmore; 5, inferior turbinated 
body; G } embryonic tooth. 




Tig. 148. — Transverse vertical section through the nasal fossse. 1, ethmoid 

cells; 2, deflection and spur of septum with adhesion to the 

left inferior turbinated body. 



TREATMENT OF HYPERTROPHIC RHINITIS. 259 

a result the constant passing of air through the throat instead of the 
nose dries the throat and larynx and gives rise to more or less irrita- 
tion or inflammation of these parts. 

"When the stenosis is marked the nasal voice is a characteristic 
sign. Invasions of the nasal ducts and Eustachian tubes lead to in- 
volvement of the conjunctivae and the middle ears. Watery eyes, 
impairment of hearing, and tinnitus annum are common sequels of 
this disease. AVhen the very young are affected the pharyngeal and 
oral tonsils are often found hypertrophied (Plates II and IT) and 
require excision. Anosmia (absence of the sense of smell) and im- 
pairment of taste are occasional symptoms. "When headaches are pres- 
ent, they are referred to the supra-orbital or frontal region. 

Asthmatic attacks are sometimes due to pressure of the enlarged 
turbinals against the septum (Fig. 17.1). The secretions, which are 
much more abundant than in health and more copious in the morn- 
ing on account of their accumulation during the sleeping-hours, cause 
a disagreeable habit of hawking and hemming to clear the throat, 
especially on rising in the morning. 

Diagnosis. — The septum, like the turbinals, is red and thick- 
ened, particularly near its base. The turbinals, instead of presenting 
a smooth, glassy surface, as in the simple form, are hypertrophied 
unevenly and sometimes present a somewhat nodular appearance. 
The inferior turbinate body usually shows the Greatest enlargement, 
but the middle one is often found in contact with the septum. Their 
posterior extremities may blossom out into berry-like buds of a gray 
or purple color (Plate V). The former are the commoner. Probe- 
pressure meets with a firm, instead of a yielding, resistance. 

Prognosis. — After middle age the hypertrophies generally become 
absorbed and disappear, when this form often merges in atrophic 
catarrh. The hearing is likely to suffer, and there is a strong pre- 
disposition to catarrhal affections of the pharynx and larynx. Mod- 
ern methods of surgical treatment afford an excellent prognosis. 

Treatment. — Cleanliness is of prime importance in this as in 
other forms of nasal catarrh. The solutions and methods given in 
treating of the simple form are indicated here, but medicinal treat- 
ment alone will not suffice to remove hypertrophies. Operative meas- 
ures must be brought into requisition. Of these the electric cautery 
is now the most frequently resorted to except for cartilaginous and 
osseous outgrowths, which require the knife, the saw, or the drill. 
Por the fibrous growths the hot or cold snare, scissors, chemical 



260 



TREATMENT OF HYPERTROPHIC RHINITIS. 



caustics, etc., are employed. We will first consider the electrical ap- 
paratus. 

For physicians who practice in the country, where the incan- 
descent electric lights are not a part of their office equipment, the 
Wabash cautery-battery (Fig. 149) is satisfactory. It has the ad- 
vantage of a mechanism which prevents the immersion of the zinc 
and carbon elements in the cautery fluid except when in use. This 
extends the life of the battery very materially. By keeping a fresh 
supply of the fluid on hand for immediate use one need never be 




Fig. 149.— The Wabash cautery battery, with electrodes, lamp, and handles. 



disappointed by the battery's not working. The Flemming battery, 
also, is effective. 

If the physician's office is wired for incandescent electric lights, 
or if he is not remote from conveniences for storing his battery, the 
one shown in Fig. 150 is to be recommended. It is more easily port- 
able than the fluid battery, and will give a white heat. Unlike the 
plunge battery, it deteriorates in consequence of disuse, and is better 
for being worked at least three times a week. When lying idle it 
sulphates; that is, sulphate of lead forms on the plates and renders 
it inoperative. 



ELECTROCAUTERY APPARATUS. 



261 



The most thoroughly useful combined electrocautery and motor 
instrument with which the author has had any experience is the 
rotary-current transformer and dynamomotor shown in Fig. 151. 
Above the transformer is seen the switch, and at the left are the 
cautery-rheostat and cautery-handle, with the cautery-snare, ready 
for use with the 110- volt direct current, such as is used in Chicago. 

The cautery-current furnished by this transformer has an electro- 




Fio-. 150. — The American storage battery 



motive force of T 1 / 2 volts and a volume sufficient to heat the largest 
cautery-electrode, and it is perfectly controlled by the rheostat: so 
that the operator has at command and under entire control the full 
range of any desired strength of current. This transformer is quiet 
in its operation, and it may be placed in the treatment-room or in 
any convenient location at a distance from the operating chair by 
extending the wires leading from the generator to the rheostat. It 
has o-iven entirely satisfactory service in mv work both for cautery 



262 



ELECTBOCAUTEBY EYXAMOMOTOB. 



purposes and for operating drills, burs, etc., in connection with the 
dental arm. For the perfecting of this superior apparatus I am under 
obligations to C. S. Neiswanger, and the Mcintosh Battery and Opti- 
cal Company, of Chicago. 




Fig. 151. — Electric current-transformer and dynamomotor. 



In many of the smaller towns the electric current employed for 
the purposes of illumination is of the alternating kind, and is trans- 
formed for house and office purposes to a pressure of 52 or 104 volts. 



ELECTRIC CURRENT-TRANSFORMERS FOR CAUTERIZING. 



263 



When this current is obtainable it is much cheaper, and more easily 
adapted to cautery uses, than the 110-volt direct current. 

A transformer for this current is illustrated in Fig. 152. The 
current from the mains enters the binding-posts on the side of the 
instrument, and by flowing through a magnetizing coil consisting of 
a large number of turns of fine wire, induces a rapidly-reversed flow 
of magnetism through a centre bundle of soft-iron wires. This flow 
of magnetism encircles the secondary coil, which, consisting of a few 
turns of very coarse wire, delivers a current of low voltage and high 
amperage to the binding-posts on the top of the instrument. 




Fis. 152.— Alternating electric current transformer tor cautery purposes. 

By means of the hand-wheel on the transformer the secondary 
coil may be raised out of the magnetic field of the primary, thus 
diminishing the current supplying the cautery electrode. In this 
manner the current is placed under absolute control: and so perfeci 
is the adjustment that a fraction of a turn of the wheel raises c 
lowers the temperature of the cautery knife a perceptible degree. The 
voltage of the current obtained may be varied at will from 2 to 1; 
volts, and it may be utilized for lighting small lamps. 

The transformer, when heating the largest cautery-knife, takes 



264 



ELECTRIC-CAUTERY INSTRUMENTS. 



from the mains about 2 amperes, and delivers to the cautery-knife 
40 amperes. The large increase of current in passing through the 
transformer is offset by a corresponding diminution of voltage. A 
large volume of current at a low voltage is what is required for cau- 
tery purposes. 

Figs. 149 and 153 show several of the most useful cautery elec- 
trodes, and Fig. 154 a convenient handle. One must select the elec- 
trode according to the individual requirements of each case. 



Fig. 153. — Cautery-knife. 

The electrodes should fit into the handle in such a way 'as to 
permit the operator's arm to rest naturally by his side while cauter- 
izing, the same as while using the nasal speculum (Fig. 121). They 
are not now so constructed, but they should be. 

If the physician does not happen to have the conveniences of the 
electrocautery, he may resort to chromic, or nitric, or monochloracetic 
acid. Of these the chromic acid possesses decided advantages over the 
others. It is fusible into an easily manageable bead on the chromic- 
acid applicator (Fig. 71). To accomplish this, the platinum loop is 
dipped into the dry acid crystals and held over a small flame to heat. 
As soon as the acid begins to melt it is quickly withdrawn from the 




Fig. 154. — Mcintosh electrocautery handle, with snare and windlass. 
It answers for snaring as well as for holding electrodes. 



flame and blown upon to cool it rapidly into the form and size of 
bead desired. One should be careful not to apply the acid on a very 
moist surface too long, or moisture will be absorbed sufficiently to 
loosen the bead and allow it to fall off the loop, and thus cauterize 
tissue that does not need it. In the use of liquid acids all the sur- 
plus fluid must be pressed out of the cotton pledget by which it is 
applied before introducing it into the nose, otherwise it will spread 
over the surrounding surface. 



ELECTBOCAUTERIZATIOX. 265 

Ten or fifteen minutes before cauterizing the mucous membrane 
an 8-per-cent. solution of cocaine hydrochlorate or eucaine is to be 
applied. It must not be sprayed into the nose, for toxic effects and 
collapse may result from an overdose. It is best to twist a piece of 
absorbent cotton loosely on the carrier (Fig. 9), dip it into the anaes- 
thetic solution, and then adjust it nicely to the particular area we 
desire to cauterize and slip it off the carrier, leaving it pressed lightly 
between the septum and turbinate. Like the liquid acids, the surplus 
of the anaesthetic solution should be pressed out in the mouth of the 
medicine-container before introducing it. The patient is directed not 
to swallow any that may trickle into his throat. In about ten or 
fifteen minutes the membrane should be sufficiently anaesthetized to 
burn without pain. It need hardly be repeated that the membrane 
must be thoroughly cleansed and dried before the treatment, for if 
thick discharges are present they prevent the action of the drug upon 
the tissues as well as weaken it by dilution. 

It is useful to instruct the patient to raise his hand if he should 
begin to experience any severe pain from the cautery. However, by 
employing a strong preparation of the anaesthetic and leaving it a 
considerable time, even twenty minutes, in contact with the membrane 
by means of the cotton pack, it is possible to burn deeply without 
causing much discomfort. There is an advantage in cauterizing 
deeply. As cicatrization takes place a furrow forms, which, together 
with the subsequent contraction, leaves a capacious breathing-space 
between the turbinate body and the septum. 

The electrode should be used at a white heat, with care that it 
does not melt, or burn out, and it must not be allowed to cool while 
in contact with the tissue, for if it does it tears away the burned 
parts during the removal, and leaves a raw, unprotected, bleeding- 
surface. It must be removed while it is still hot, care beins: taken to 
avoid touching any but the anaesthetized area. If the electrode is 
permitted to touch the border of the naris in its withdrawal, the re- 
sulting burn will cause much annoyance. 

Only a small area should be cauterized at one treatment. Not 
more than one-third or less of the turbinate body should be treated 
to a single cauterization, for if more is included the reaction occa- 
sions considerable swelling, a copious serous discharge, pain, headache, 
irritation of the corresponding eye, and even tumefaction and dis- 
coloration of the cheek and loose areolar tissue of the lower eyelid. 
It is generally best to allow about a week to intervene between cauter- 



266 ' ELECTKOCAUTERIZATION. 

izations of the same side, but when patients from a distance can re- 
main but a brief period the opposite nostril can be burned in about 
four or five days after the first, if the burned areas are not too ex- 
tensive. 

After each cauterization the most satisfactory results are obtained 
by introducing a light packing between the burned surface and the 
septum, consisting of a thin pledget of cotton moistened with a 10- 
per-cent. solution of camphor-menthol in lavolin or benzoinol. The 
packing is only large enough to cover the cauterized area with slight 
pressure, and not enough of the solution is used to press out and run 
from the nose. This is exchanged for a fresh dressing daily for four 
or five days, when the tissues will appear shrunken and mummified 
instead of swollen, succulent, and covered with a slough, as they do 
without this method. Under the treatment outlined there is i; ttle 
or no haemorrhage, pain, or reaction, but the parts pursue a placid 
course to recovery. 

The use of the cautery is really a simple operation, but care must 
be exercised to not approach too near the orifice of the Eustachian 
tube. We have seen acute suppurative inflammation of the middle 
ear result from such procedures. Seiss (Therapeutic Gazette, Novem- 
ber 15, 1891) cites cases of ear disease made worse by nasal treat- 
ment. The membrane being anaesthetized, a speculum is introduced 
and the light from the forehead-mirror is thrown into the nostril. 
The chosen electrode is introduced cold and placed on the benumbed 
area, when the current is turned on sufficiently to give a white glow. 
If the patient evince pain, or if the electrode is seen to burn as 
deeply as is desired, the current is interrupted and at the same in- 
stant the electrode is moved outward so as to part from the tissues 
before cooling. If the whole lower turbinal is hypertrophied, the 
anterior third is cauterized first and at intervals of about a week the 
contraction and consequent opening will be sufficient to admit of 
treating the middle and posterior thirds. 

Unless the camphor-menthol packing is used, swelling and 
sloughs occlude the passage until about the fourth or sixth day, when 
the sloughs separate. When the cauterization is extensive or deep, 
some considerable pain may be experienced for a number of hours, 
unless a pledget of cocainized cotton is left covering the surface. 
Occasionally a little pain is experienced in the upper incisors. If the 
septum is not hypertrophied the electrode should be kept away from 
it, and the burning is not carried deeply enough to include the peri- 



SUEGICAL TBEATMENT FOR HYPEETEOPHIC RHINITIS. 267 

osteum. If suppuration is feared, glycozone may be substituted for 
the camphor-menthol. 

Acute pharyngitis and ulcerative tonsillitis occasionally follow 
closely upon nasal cauterization, especially if the cauterization be 
quite extensive as to surface area or depth. The patient will be less 
likely to have pain, sneezing, and discharge from his nose after the 
operation if one or more coryza tablets are given. 

On the days following cauterizations the nose is sprayed with 
the antiseptic solutions already mentioned, and then by a 4-per-cent. 
solution of eucalyptol in lavolin, or the same strength of pine-needle 
oil, or benzoinol. 

For posterior hypertrophies Seiss prefers curettement. The snare 
(Fig. 155) is preferred by many specialists. It is introduced with 
the loop open, as shown in Fig. 154, and passed over the enlargement 
so as to engage it as near its base as possible, when, by drawing- 




Fig. 155. — Hobby's steel snare. 

upon the wire or turning the wheel, the loop is made to sever the 
tissues. The Jarvis transfixing needle facilitates this maneuvre. The 
needle is passed through the hypertrophy until it projects beyond: 
the snare-loop is passed over both ends of the needle so as to lie on 
its under surface and to cut between the needle and the base of the 
growth. The cutting is done by a turn of the wheel at a time, taking 
from one-half to an hour for the operation. The more time, the less 
haemorrhage. In removing posterior growths the rhinoscopie mirror 
is required, in order to view the field of operation (Plate V, Xo. 2). 

When deformities of the cartilaginous septum necessitate their 
removal, this is best accomplished by means of a specially fashioned 
knife having a tapering, blunt point (Fig. 156). After anaesthetizing, 
the hypertrophy is severed by entering the blunt probe-point of the 
knife below and cutting upward. In this manner the occlusion of the 
field by haemorrhage is avoided if the cutting is done expeditiously. 



268 



ATKOPHIC BHIXITIS. 



Exostoses are sawed off in a like manner (Fig. 157). The motion 
of the saw should be rapid, and one should not bear too hard upon 
the handle so as to make the saw catch and stick. With practice one 
can work rapidly with this instrument. The electric drill is a very 
efficient instrument and is~ manipulated like a dentist's drill (Fig. 1). 



Fig. 156. — The author's septum-knife. 

When the turbinate bone becomes enormously hypertrophied, 
turbinotomy is resorted to in order to remove the entire bone. This 
is accomplished with the saw; but this operation is seldom necessary. 
William Scheppegrell and G. Melville Black (The Laryngoscope, No- 
vember, 1897) have devised electromotor saws for operating in the 
nasal cavities. 

Hygienic measures and internal treatment must be employed 
according to the indications and on general principles, and the mat- 
ter of clothing is considered in the treatment of acute rhinitis. 




Fie-. 157. — The author's nasal saws. 



Ateophic Ehinitis. 

Synonyms. — Ozsena; fetid catarrh; cirrhotic rhinitis, etc. 

Pathology. — This form of nasal catarrh is a sequel of a pre- 
existing inflammation; indeed, it may be said to be the third stage 
of rhinitis in the logical order in which we have treated of the sub- 



TKEATMENT OF EPISTAXIS. 273 

ice-bag (Fig. 83) is a convenient means of using continuous cold. 
Pulverized alum and tannin are useful. The latter is used in powder 
or, as mentioned later, in connection with tampons. A 10-per-cent. 
solution of cocaine on a cotton pledget packed firmly between the 
bleeding-point and the opposite wall is effective. 

It is sometimes difficult, even with good reflected light, to locate 
the source of haemorrhage, but this should be accomplished if pos- 
sible. Antipyrin in 3-per-cent. watery solution or in powder and the 
liquor ferri perchloridi are useful. Some writers speak highly of the 
electrocautery, but the author cannot indorse it for this purpose. 

If the simpler measures fail, resort must be had to tampons. 
The following method is most efficacious: A long strip of lint, linen, 
or cotton cloth, three-eighths of an inch (one centimetre) wide, is 
immersed in a saturated solution of tannic acid in water, and then 
the water is pressed out, leaving the cloth thoroughly medicated. 




Fig. 158. — Bellocq's cannula introduced. 

One end of this is carried by the delicate angular forceps or probe as 
far into the nose as the case requires. Then the remainder of the 
tampon is packed in, a small loop at a time, until it is pressed firmly 
into all the sinuosities, and the cavity is completely filled. Any sur- 
plus of the strip is then cut off. 

Should tamponing of the anterior naris fail, posterior plugging 
must be added to it. In this case the posterior nares must be plugged 
first, as follows: Bellocq's cannula (Fig. 158) is threaded through the 
eye in the end of the spring with a strong string. The thumb-screw 
is adjusted so that it will throw the spring out after its introduction, 
as shown in the cut. Then the sound is introduced like the Eusta- 
chian catheter until the distal extremity projects downward over the 
velum palati. At this moment the spring is extruded until it, with 
the string, is seen through the open mouth. With hook or forceps 
one end of the string is brought out of the mouth and a pledget of 
cotton or lint as large as an adult's thumb is tied firmlv to it. This 



274 NASAL POLYPI. 

is drawn backward and upward through the mouth and throat into 
the posterior nares. It should be made to plug effectually both poste- 
terior nares, for otherwise haemorrhage might continue through the 
free one. In passing the tampon behind the palate, the finger should 
be introduced to prevent drawing the palate upward with the cotton. 
Then the finger can pack the tampon well into the nares. The string 
protruding from the anterior naris is fastened back of the ear with 
adhesive plaster. In hot weather this must be watched, or the per- 
spiration will loosen it and allow the tampon to become displaced or 
swallowed. After a day or two the packing must be removed to pre- 
vent septicaemia. In the absence of Bellocq's cannula the Eustachian 
catheter can be substituted, and the writer has succeeded with a silver 
male catheter in an emergency. 

Constitutional treatment may be required, — iron, ergot, etc. 

Nasal Polypi. 

There are three varieties of benign neoplasms to which the term 
"nasal polypi" is applied: mucous, fibrous, and cystic. 

MUCOUS POLYPI. 

These occur in multiple form, and sometimes they are very nu- 
merous (Plate III). They are a pale-pink or ashy-gray color, and are 
most troublesome in damp weather, when they absorb moisture, caus- 
ing them to swell and occupy increased space. They are usually 
found in middle life, from 20 to 40 years, and occasion stenosis of 
the nares and mouth-breathing (Fig. 185). The mucoid variety is 
the most common. Patients often observe movements in these polypi, 
which are occasioned by forcible currents of air in sniffing or blowing 
the nose. 

They are generally attached either to the middle turbinal or to 
the outer wall of the middle meatus. (See "Treatment," below.) 

FIBEOUS POLYPI. 

This variety presents a single, dense, resisting surface to the 
probe. It may develop into so large a mass as to invade the naso- 
pharynx (Plate V) or project from the nostril. It causes stenosis 
and supra-orbital headache, and its expansion causes pressure and 
deflection of the septum, as well as absorption of the turbinals. Ne- 
crosis of the bones and invasion of the adjacent sinuses may occur. 



TREATMENT OF XASAL POLYPI. 275 

The nose in some cases is bulged outward at the sides, which gives 
the arch a flattened appearance. (See "Treatment," below.) 

CYSTIC POLYPI. 

These are very rare, and consist of a cyst or sac filled with a 
yellowish or bloody, serous fluid. 




Fig. 159. — Curette-forceps. 



TREATMENT. 



Polypi should be removed preferably with the cold-Avire snare 
(Fig. 155). The loop of the snare is introduced expanded, as seen in 
the electric snare (Fig. 15-1), and made to embrace the pear-like tumor 
and to slide up to its attachment. The polypus is then slowly cut off 
and the point of attachment is cauterized with the electrocautery or 




Fig. 160. — Very strong cutting forceps. 

chromic acid to prevent a return of the growth. This is preferable to 
removal with the forceps or scissors, and if the evulsion is not too 
rapidly accomplished little haemorrhage ensues. The biting-curette 
forceps (Figs. 159 and 160) are especially serviceable for searching out 
and removing the mere buds of polypi in the upper nasal passages. 



2*76 XASAL TUMORS. 

After-treatment is the same as after removal of hypertrophies, already 
given. 

Papillomata. 

These are benign neoplasms of infrequent occurrence. They 
may be single or multiple, and are most often attached to the lower 
part of the septum or inferior turbinal. (See "Treatment" under 
"Erectile Tumors.") 

Erectile Tumors. 

These are very rare. They have the appearance of an hyper- 
trophy of the turbinate body, except that pulsation can be detected 
in them. This is in consequence of their close relationship to an 
artery, and their removal is likely to be attended with considerable 
haemorrhage. 

Treatment consists in removal of the growths either by chemical 




Fig. 161. — Casselberry's saw-tooth scissors. 

or mechanical means. Chromic acid or the galvanocautery may suf- 
fice, or the nasal scissors (Fig. 161) may prove preferable. 

Choxdromata. 

Cartilaginous tumors are rare growths occurring about the age 
of puberty and springing from the septal cartilage. Their location, 
unyielding firmness, and sessile shape distinguish them from fibro- 
mata. The color is a light pink, and they have not the smooth sur- 
face of fibrous tumors, but are indented by numerous depressions. 

Treatment. — If these growths prove troublesome they should be 
removed. Many methods are in use, — the knife, saw, chisels, punch, 
dental or electric drills and trephines, the electrocautery, etc. 

The cartilaginous growth is easily removed, under cocaine or 



XASAL GROWTHS. 277 

eucaine, by the authors septum-knife (Fig. 156). The cutting should 
be done as already described, and care should be taken not to per- 
forate the septum. It is claimed by some rhinologists that healing 
does not take place so readily after the electrocautery as after cutting, 
but the author has not been able to confirm this opinion. 

OSTEOMATA. 

The bony tumors also are very rare. They are offshoots from 
the mucous membrane and the product of an osseous degeneration of 
connective tissue. Their pressure produces headache, asthenopia, 
occasional haemorrhages, and ulceration with a purulent discharge. 
Unlike rhinoliths, they resist a needle and do not crumble. (See 
"Treatment" under "Exostoses.") 

Exostoses. 

Osseous growths are frequently met with in the nose. They usu- 
ally take the form of ridges or spurs upon the bony septum, encroach- 
ing upon the lumen of the passage sometimes to a considerable ex- 
tent. Occasionally the growth attains to very large proportions 
until pressure is produced on the opposite turbinal or adhesion to it 
occurs, forming a synechia or bridge across the canal. Figures 143, 
144, and 172 show such conditions. In Fig. 143 the probe is inserted 
to the point of adhesion between the exostosis and the inferior turbi- 
nate bone. The contour of the latter will be seen in Fig. 144 to have 
been altered by the pressure, from a convexity, like the opposite one, 
to a concavity. The septum is deflected toward the exostosis. 

These growths arise from the periosteum and may occasion no 
inconvenience if no pressure is exerted on surrounding tissues, but 
when they impinge on the posterior portion of the inferior turbinal, 
reflex asthma may result. They are hard, immovable, light pink, and 
bleed easily on pressure with the probe (Plate TV). They may cause 
headache, amblyopia, and other ocular disturbances. 

Treatment. — Osteomata and exostoses should be removed when 
they have attained to such a size as to occasion symptoms of their 
presence. The former may be removed by the snare, strong saw- 
tooth scissors, curette, or forceps; the latter by the saw (Fig. 157). A 
strong solution of cocaine must be used, preferably 20 per cent. The 
electric trephine and drills are convenient for this purpose, and the 
•dental motor also is effective. 



278 



RHINOLITHS. 



Rhinoliths. 

Deposits of the salts of the nasal secretion are infrequently found 
in the nasal chambers and are, in effect, foreign bodies. They are 
generally found in the anterior part of the cavities, and are of irreg- 
ular shapes and sizes and of gray or dark color. The discharges en- 
velop them and obscure their identity until washing reveals their 
nature. Ehinoliths may develop to such a size as to obstruct the 
nasal passages and give rise to a foul discharge and epistaxis. The 




Fig. 162. — Destruction of the hard palate, the soft palate remaining 
unharmed. Through the very spacious perforation in the hard palate is 
seen a dark object with round and roughened surface: 1, a myaloid sar- 
coma. 

treatment consists in their removal as detailed under the heading 
"Foreign Bodies in the Nose." 



Sarcomata of the Nose. 

These are, fortunately, rare occurrences. Sarcoma and carcinoma 
are sometimes developed in this region. Sarcoma does not differ in 



MALIGNANT GROWTHS IN THE XOSE. 279 

this locality from its characteristics in other situations. It is more 
likely to be found on the septum, but may invade the other nasal 
walls. It gives rise to pain, obstruction of respiration, fetid dis- 
charge, and possibly difficulty in swallowing and impaired hearing 
when it extends to the naso-pharynx. If it invade the nasal vault the 
cranial cavity may become involved, resulting in a fatal termination. 

Sarcomata are of rapid growth, and present a dark, roughened 
surface in some instances; in others they are pale. Fig. 162 shows 
a myaloid sarcoma springing from the inferior turbinated body of a 
syphilitic. I am indebted to the courtesy of E. Pynchon for a photo- 
graph of this case. As pressure develops laterally, bulging of the 
nasal walls becomes apparent in the contour of the nose and the 
prominence of the eyes. The gravity of the disease is manifested in 
a general constitutional disturbance. The probe causes bleeding and 
discovers a soft, fleshy mass. This is a rapidly-fatal disease of less than 
a year's duration. 

Treatment. — Complete extirpation is the only remedy. Ano- 
dyne and astringent applications after the disinfecting and cleansing 
washes are only palliatives. 

CARCTX03IA. 

Cancer of the nasal passages differs in no way from the same dis- 
ease elsewhere. An ulcerating surface with a brown, serous fluid, pain 
and haemorrhage, infiltration of the cervical glands, and constitutional 
symptoms characterize this disease. The end is death. 

Treatment. — There is no certain curative treatment. The growth 
may be somewhat retarded and the suffering ameliorated by anodyne 
and astringent applications. Cocaine and aristol are the best. Hasse 
and others report good results from interstitial injections of alcohol. 
Those are treated of under the heading of "Treatment" in "Carcinoma 
of the Pharynx." 



CHAPTEK XXIV. 

DISEASES OF THE NASAL CAVITIES, CONCLUDED. 

Tuberculosis of the Nose. 

Fortunately tins is a rare affection. It appears in two dif- 
ferent forms: an ulceration and a neoplasm, or tumor. The nicer 
appears on trie septum near the orifice of the nostril, and may extend 
from this point to other parts of the nose and it may even invade 
the upper lip. It is more likely to be secondary to tuberculous affec- 
tions of other organs than a primary manifestation. The ulcer ap- 
pears as a yellow or gray surface with a round, elevated, uneven 
border. There is a purulent discharge, more or less tinged with blood, 
and of a disagreeable odor. There is no tendency toward cicatrization, 
and after being once healed it has a strong disposition to break out 
again. Pain is not a common symptom. Sooner or later the disease, 
which is now generally conceded to be clue to the bacillus tubercu- 
losis, invades the larynx and lungs and terminates in death. 

See "Pathology" of "Tuberculosis of the Larynx," page 494. 

Treatment. — Cleansing, antiseptic solutions, such as are noted in 
Chapter XYIII, must be freely used. Curettement, the electrocau- 
tery, chromic or lactic acid, — the latter in 50-per-cent. strength, — 
may be resorted to for the removal of the caseous, tuberculous material 
that forms the base of the ulcer. In case of a tumor, it should be 
removed with the snare and the attachment-surface should be cau- 
terized. Astringents and iodoform are useful in retarding disintegra- 
tion and the invasion of adjacent structures. If pain is present, mor- 
phine, cocaine, or eucaine may afford temporary relief. Codliver-oil 
should be given, and guaiacol in doses of 1 to 10 minims after each 
meal. This is best administered in glycerin, milk-broths, or wine. 
Creasote is often useful. For other remedies consult the sections on 
"Tuberculosis of the Pharynx" and "Tuberculosis of the Larynx." 

Syphilis of the Xose. 

The manifestations of syphilis in the nose correspond to the 
three stages of syphilis occurring in other organs. It may be heredi- 
(280) 



SYPHILIS OF THE XOSE. 



281 



tary or acquired. In the former it appears either before the third 
month of ehildlife or between the third year and the beginning of 
adolescence. In infants the affection simulates coryza, but tends 
strongly toward suppuration. The discharge is more acrid and irri- 
tating than that of simple rhinitis, and produces a red and raw ap- 
pearance of the upper lip. The borders of the nostrils are cracked 
and chapped. Xasal respiration is embarrassed, and, in consequence of 
the interference with sucking, the babe is ill nourished and puny. 
If the disease attack the cartilage or bone, an offensive odor is im- 
parted to the discharge. 




Fig. 163. — Destruction of the bones forming and supporting the bridge 

of the nose. 



The later form of hereditary syphilis presents manifestations of 
the tertiary form. It attacks the cartilaginous and osseous septum 
and then the turbinate bodies, and by carious and necrotic processes 
they undergo more or less complete destruction. The supports to 
the end and bridge of the nose disappear and the end may drop down 
toward the upper lip, or, if it remain supported by a remnant of the 
cartilaginous septum, the centre of the bridge may cave in and pro- 
duce the exaggerated pug-nose deformity (Figs. 163 and 164). 

Diagnosis.- — "With care one will be able to distinguish the obsti- 
nate, persistent, pus-producing rhinitis of a syphilitic infant from an 



282 



TKEAT3IEXT OF SYPHILIS OF THE NOSE. 



ordinary cold in the head which in an uninfected child tends toward 
speedy resolution. Mucous patches may be discernible in the nares 
and a papular eruption on the skin. These children are often badly 
nourished, old looking, and unpromising. After taking into account 
all the characteristics mentioned, if in the later form there exist any 
doubt as to the nature of the disease, a course of antisyphilitic treat- 
ment will dispel the uncertainty. 

Prognosis. — If the pathological process has not involved the 
cartilaginous or bony walls, and if the patient is not greatly debili- 
tated, the chances of recovery are good. 




K : '''W: 




Fig. 164. — Partial destruction of the bones of the nose, resulting in 
two perforations: one in the centre of the bridge and another at the 
inner angle of the right eye. (From the author's clinic.) 



Treatment. — Cleanliness and specific medication are often re- 
warded by brilliant results. The antiseptic sprays given in Chapter 
XVIII are indicated, after which tincture of iodine applied to the 
ulcerating surfaces will be followed by healthy granulations and cica- 
trization. If the ulcers do not cicatrize promptly, it is advantageous- 
to dust the parts with aristol or nosophen (Fig. 34) after the cleans- 
ing process. We generally use the mixed treatment, — small doses of 
mercury with potassium iodide. The latter may have to be given in 



LUPUS OF THE NOSE. 283 

increasing closes until the system is saturated. This treatment, vigor- 
ously pursued and carefully watched, gives gratifying results. 

In great debility and malnutrition codliver-oil, malt, tonics, and 
improved sanitary surroundings may be necessary. When extensive 
deformity of the nose takes place, it may become necessary to resort 
to a rhinoplastic operation to restore the contour and continuity of 
the organ. When the cartilaginous support of the end of the nose 
has been destroyed so as to let the tip fall upon the upper lip, the 
author has restored the natural lines by a device shown in Fig. 165, 
which he has named a "nasal supporter." It is fashioned to fit into 
the tip of the nose, so that the sides or wings of the supporter will 
correspond to the alae nasi. It is so placed as not to be visible when 
in position. They were first constructed of aluminium, but the bright, 
reflecting surface was observable. Later I experimented with vulcan- 
ized rubber, and found that, after making the surface a dull black, 




Fig. 165. — The author's nasal supporter. 

it answered all requirements. The improvement in the facial appear- 
ance after restoring the pendulous nose to its normal position is some- 
thing to be appreciated. 

Destruction of the major portion of the septum nasi does not 
necessarily result in external deformity. The writer has under ob- 
servation such cases in which there is no external discoverable evi- 
dence of the internal architectural desolation. 

Lupus of the Nose. 

Lupus affecting the nasal cavities is a rare affection except as 
an extension of primary lupus of the face or pharynx. The nodules — 
which are found more abundantly on the septum than on the turbi- 
nals — break down, ulcerate, and discharge a foul-smelling, purulent 
secretion. In and about the prominent border of the ulcer can be 
seen the hard, but resilient, tumefactions, or nodules. As the dis- 



284 GLANDERS. 

charges dry upon the ulcers, brown or greenish crusts form, offering 
more or less obstruction to the nasal respiration. Pain, radiating to 
the surrounding structures, is complained of, and the ulcer is sensi- 
tive to touch. This is easily differentiated from ozsena. 

Treatment. — In addition to the detergent and antiseptic sprays 
mentioned in treating of ozaena, etc., the treatment is the same as 
that given for lupus of the ear. 

Glanders. 

Glanders is a disease derived from the horse and is encountered 
among horse-farriers, coachmen, etc. It is due to a specific contagion 
and manifests its presence by the formation of pustules which give 
way to ulcers of the skin. It attacks the nose and throat, from which 
a bloody pus is discharged in large quantities. Constitutional symp- 
toms characteristic of a serious systemic invasion or toxaemia indicate 
the gravity of the disease. When the infection extends to the lym- 
phatic glands and skin in various parts of the body it is termed 
"farcy." 

This disease is either acute or chronic. The acute form is ush- 
ered in by symptoms similar to those of the eruptive fevers: chills, 
nausea, vomiting, fever, and red rash on the nose and face resembling 
erysipelas. This is followed by the appearance of blisters, which 
burst and leave their contents on the skin to dry into crusts. On 
removing these an ulcerating surface is disclosed that shows no in- 
clination to heal, but rather to extend over the surrounding parts. 
The pustular eruption invades the nose and throat, causing embar- 
rassment of respiration. The copious, tenacious discharges from the 
nose and throat, and sometimes from the eyes, keep the patient oc- 
cupied to free the passages. In the chronic variety the secretion is not 
so copious, and it may be lacking, except in the desiccated form of 
scabs on the nasal and pharyngeal membrane. 

Symptoms suggestive of tuberculosis come on later: colliquative 
diarrhoea and sweats, huskiness of the voice, and difficulty of degluti- 
tion and respiration from tumefaction of the mucous membrane of 
the pharynx and about the glottis. Great prostration and delirium 
precede death. 

The acute form is rapidly fatal, lasting only about a week, while 
the chronic variety may persist for several months or a year. About 
half of all the cases die. 

The diagnosis may be obscured by the many symptoms that are 



FURUXCULOSIS OF THE XOSE. 2So 

characteristic of oilier affections, such as typhoid fever, rheumatism, 
syphilis, pyaemia, etc., but the history of the patient, exposure to in- 
fection from horses, and lack of further pathognomonic symptoms of 
other diseases must be considered. As distinguished from typhoid, 
we have the pronounced nose, throat, and skin eruptions and dis- 
charges and ulcerations; from articular rheumatism, pains in the 
muscles and tenderness surrounding the joints; from syphilis, the 
constitutional disturbance and absence of proving by specific reme- 
dies; from pyaemia, even when abscesses are found there is little or 
no chilliness. 

Treatment. — Xo antitoxin has yet been evolved that acts as a 
specific for this disease. From the nature of the case it is to be ex- 
pected that such a remedy will yet be found. Xo treatment so far 
tried has a decided influence in curing or retarding the progress of 
this virulent affection. It must be left to the practitioner to meet 
symptoms and indications as they arise and appeal to his knowledge 
of the general principles of medicine. 

FURUXCULOSIS OF THE X"OSE. 

Boils in the nose are a common source of discomfort. They 
occur repeatedly in some individuals and cause soreness, redness, and 
swelling of the end of the nose, lasting about a week. Small furun- 
cles often develop just within the opening of the nostril, especially 
on the upper border, and originate in a hair-follicle. They render 
blowing and wiping the nose very painful. 

Treatment consists in local and constitutional remedies. To the 
boil situated within the border of the naris a pledget of cotton may 
be applied after moistening it with a 10-per-cent. solution of cam- 
phor-menthol in lavolin or benzoinol, or a 12-per-cent. solution of 
carbolic acid in glycerin may be substituted, as recommended in the 
treatment of furuncle of the ear. When pus is found it is evacuated, 
giving an opportunity for the remedies to enter the cavity. This 
treatment should be followed by the application of the yellow-oxide- 
of-mercury ointment, 5 grains to the ounce in vaselin, or the car- 
bolic-acid ointment. Sulphide of calcium has a reputation of repress- 
ing or preventing pus formation, and can be given in those cases 
in which recurring crops of furuncles torment the patient. The 
author has used with satisfactory results arsenious acid in doses of 
1 / 30 grain three times a day, increasing gradually to two or three 
times that quantity for a short time, until the patient was free from 



286 LOSS AND PERVERSION OF THE SENSE OE SMELL. 

these symptoms, and, if they reappeared after a few months, repeat- 
ing the treatment with larger doses .continued for a longer time. 
This treatment has been successful in breaking up what appeared to 
be an established habit of body in which furuncles broke out with 
every spring opening. 

Anosmia. 

Absence or loss of the sense of smell may be due to central lesion 
or peripheral diseases. Affections of the Schneiderian membrane may 
destroy the nerve-termini or offer such obstructions as to render them 
inaccessible to odors. Acute inflammation of this membrane and 
suppuration of the adjacent cavities, such as the frontal sinuses, that 
cause the membrane to become bathed in purulent discharges, and 
syphilis and atrophic rhinitis, ozasna, etc., — that produce destruction 
of the membrane, — cause, on the one hand, temporary impairment 
or absence of the function of the olfactory nerve, and, on the other, 
irreparable loss of smell. 

Blows in the region of the olfactory bulb, and occasionally in 
other parts of the skull, cause injuries to the bulb from which it does 
not recover. Excessive tobacco-smoking, snuff-taking, and opium- 
using either blunt or obliterate the sensibilities of the olfactory nerve. 
The sense of taste generally surfers more or less in all these instances. 

Treatment. — Anosmia due to acute inflammation of the nasal 
and connecting cavities generally disappears when the cause of it is 
removed. The appropriate treatment then is the same as for the 
inflammation that produces it. When the loss of smell has existed 
for several years the outlook for its restoration is not encouraging. 
Yet the writer has seen a partial return after the whole mucous lining 
of the nasal cavities had gone through a protracted siege of ulcera- 
tion in consequence of an irregular physician's spraying the cavities 
with a corroding fluid by mistake, resulting in a complete loss of the 
sense. To complicate the case there was syphilitic infection. In such 
cases the treatment detailed for syphilis of the nose and ozasna is 
appropriate. Absolute cleanliness and nerve-tonics, such as strychnia 
and the faradic current, are indicated. The negative electrode is 
placed over the root of the nose and the positive on the occiput, both 
electrodes being saturated with salt water. 

Parosmia. 

In parosmia the sense of olfaction is perverted. This happens 
even where the sense is normal for all objective odors. Various sub- 



DEFORMITIES AND DISEASES OF THE NASAL SEPTUM. 287 

jective odors are complained of, all disagreeable, such as oils, carrion, 
kerosene, etc. A physician under my care is annoyed by a constant 
subjective odor of "greasy rags or soap-grease.' 7 This symptom may 
be due to disease of the nasal mucous membrane, the decomposition 
of retained nasal secretions, disease of the olfactory nerve, or cerebral 
lesion and over-stimulation of the nerve. As an example of the 
latter: I have under treatment a gentleman who for many years has 
been engaged in the perfume business, and during that time has grad- 
ually lost his sense of smell without any apparent causative lesion in 
the nasal cavities. Perverted olfactory function has been observed 
in the insane and epileptics. 

Treatment. — If the nasal membrane is diseased and if hypertro- 
phies, polypi, etc., are present to account for increased, retained, and 
perverted secretions, suitable treatment, such as has already been dis- 
cussed for these conditions, may remove the disgusting symptom, but 
if the cause lie in the nerve or its origin, or exist in the imagination 
as an hallucination, the indications for treatment are not so plain. 
If the olfactory bulb is the seat of the disease, galvanization or faradi- 
zation, as mentioned for anosmia, may prove beneficial. 

Deformities and Diseases of the Nasal Septum. 

Exostoses ecchondromata and synechias have already been con- 
sidered and are illustrated by Figs. 143 and 144 and Plate IV. It 
is unusual to find a nose with an interior that is architecturally syin- 
metrical. The septum in many instances is either curved (Figs. 166 
to 172), thickened, or even doubly curved so as to present a sigmoid 
flexure or a corrugated appearance. If the deformity is not sufficient 
to produce pressure on the turbinate bodies and consequent irritation, 
epistaxis, and obstruction to nasal respiration (Plate IY), no symp- 
toms referable to the anomaly are present. According to Zuckerkandl, 
the septum is not found deviated before the seventh year, but the 
author has under observation a boy 5 years and 9 months of age with 
deflection, spurs on both sides, hypertrophied turbinals, and adenoids. 

The causes of malformed septa are not known, but the theories 
are many. 0. B. Douglas believes that "traumatism is a more fre- 
quent cause than all the others combined. Pressure at birth is doubt- 
less a cause in certain cases" (The Laryngoscope, March, 1898). J. 
W. G-leitsmann attributes deflections of the septum nasi to the press- 
ure upon the septum from below by the abnormally-high arch of the 
roof of the mouth, occasioned by mouth-breathing in consequence of 



288 



DEFORMITIES OF THE NASAL SEPTUM. 




Fig. 166. — Moderate deflection of the septum nasi. The deflection 
generally involves more or less of the cartilaginous portion of the septum 
and may extend to its anterior, free border. In the latter case the lumen 
of the anterior naris is diminished, and the breathing space is seriously 
encroached upon. 




Fig. 167. — Deflection of the septum nasi sufficient to cause stenosis of 
the left nostril ; capacious right naris at the expense of the left nostril. In 
this condition pressure of the septum on the turbinals may cause sufficient 
reflex irritation to provoke asthma, hay fever, ocular disturbances, and 
other reflex neurasthenic symptoms. 



DEFORMITIES OF THE XASAL SEPTU.M 



289 




Fig. 1G8. — Deflection of the septum nasi toward the right side, at nearly 
a right angle. Such deformities are characteristic results of fractures of 
the osseous septum by falls or blows upon the nose, particularly in child- 
hood. The pressure on the opposing turbinals results in their atrophy, 
while the opposite turbinated bodies are often found hypertrophied. 




Fig. 169. — Deflection of the septum nasi toward the left side with ap- 
parent, but not real, adhesion to the left inferior turbinated bone. Such 
deformities extending throughout the cartilaginous portion of the septum 
are accountable for the tilting of the tip of the nose to one side of the 
median line, producing the crooked-nose deformity. 

10 



290 



DEFORMITIES OF THE NASAL SEPTUM. 




Fig. 170. — Perpendicular portion of the ethmoid bone, consisting of two 

plates; the inferior turbinated bone of the left side 

is plainly visible. 




Fig. 171. — Transverse vertical section through the nasal fossae. 1, 
deflected septum nasi in contact with the left inferior turbinated body; 
its deflection toward the left side has caused atrophy of the left middle 
turbinal, and has permitted an hypertrophy of the right middle turbinal. 
2, two maxillary antra of the left side, while there is only a single one on 
the right side. 



TREATMENT OE DEFORMITIES OF THE XASAL SEPTUM. 



291 



adenoid vegetations in the vault of the pharynx. The deflection may 
be so exaggerated as to give a twisted or bent appearance to the whole 
nose. The irregularity is limited mostly to the anterior and middle 
sections of the septum. 

Symptoms of nasal irritation — epistaxis, discharges, reflex neu- 
rosis (such as asthma), nasal voice, naso-pharyngeal catarrh, etc. — 
result from considerable septal deformities. The diagnosis is readily 
made on inspection with brilliant, reflected illumination. 

Treatment. — If the deformity is limited to the cartilaginous sep- 
tum the most satisfactory procedure in my experience has been the 
amputation of the offending projection by means of the septum-knife 




Fig-. 172. — Transverse vertical section through the nasal cavaties. 1, 
ethmoid cells; 2 3 right maxillary antrum; 3, deflected septum, and spur 
with adhesions (synechia?) to the inferior tiirbinal and to the floor of the 
meatus; 4, the maxillary antrum should be above this line, but it is 
absent. 



(Fig. 156). The method is described in connection with the figure. 
We have always taken pains to avoid perforating the septum, but we 
have seen many cases in which surgeons had made large apertures 
without any unpleasant consequences. AVhen the bony partition is 
involved the saw or the drills are called for. Various punches have 
been constructed to fracture and restore the deviated septum, after 
which bougies (Fig. 142), splints, and tampons are employed to main- 
tain the reduced deformity in proper position. 



292 DISEASES OF THE NASAL SEPTUM. 

BLOOD-TUMORS OF THE NASAL SEPTUM. 

Haemorrhage takes place between the mucous membrane and the 
cartilage from blows, etc. Fractures of the septum occasionally result 
in hamiatomata, These tumors are easily recognized and should be 
opened before their contents degenerate into a purulent mass, result- 
ing in abscess. (See "Treatment" under "'Abscess,'' below.) 

ABSCESS OF THE NASAL SEPTUM. 

Like blood-tumors, abscesses are generally in the cartilaginous 
portion of the septum. They may assume such proportions as to com- 
pletely blockade the nostrils and compel mouth-breathing. In a case 
recently under my care the swellings were symmetrical and had at- 
tained such a size as to protrude sufficiently from the nostrils to be 
plainly visible. They are usually the result of blows, and their his- 
tory and appearance render the diagnosis easy. 

Treatment. — Abscesses of the septum, like blood-tumors, should 
be opened, their contents evacuated, and the cavities cleansed with 
hydrozone. Then equal parts of alcohol and tincture of iodine should 
be injected so as to wash out the cavity. The dressing is completed 
by packing aristol gauze between the opposite wall and the septum 
so as to cause coaptation of the separated mucous membrane to the 
cartilage again. This method may prevent perforation of the cartil- 
age, which is a frequent sequel of these diseases. 

PERFORATION OF THE NASAL SEPTUM. 

An aperture is not infrequently found in the cartilaginous part 
of the septum when patients are unaware of its presence (Plate III), 
but occasionally a small perforation causes a whistling sound as the 
current of air moves rapidly over it, annoying the patient and at- 
tracting the attention of others. A prominent educator of my ac- 
quaintance was troubled in this manner. He was apparently in excel- 
lent health and there was no assignable cause for the anomaly. Per- 
forations are usually considered as indicative of syphilis, but they are 
not necessarily so. We have often been unable to trace them to any 
specific taint. They may occur as the result of impaired nutrition 
or the habit of picking the nose with the fingers. Abrasions are pro- 
duced, and the crusts that form over them are not allowed to remain 
until healing occurs beneath. In the course of exhausting diseases, 



FRACTURES OF THE NOSE. 293 

such as tuberculosis and typhoid pneumonia, the septum may become 
perforated. 

Treatment. — Unless the perforation causes a whistling sound per- 
ceptible to others or annoying to the patient, no treatment is required 
except the application of benzoinol or some stimulating ointment to 
the border of the perforation. Treatment does not result in its 
closure. If disagreeable sounds are produced the opening can be 
changed in shape so that its long axis shall correspond to the air- 
current. 

In operations on the nose Delavan {Journal of Laryngology, 
1895) deprecates perforating the vomer on account of the dispropor- 
tionate shock resulting. French {New York Medical Journal, De- 
cember 1, 1894) perforates the septum when necessary for breathing- 
space, but insists on proper after-treatment, and Wright insists on 
thorough antiseptic treatment before and after operations on the nose. 



Fractures of the Xose. 

The bones of the nose are not easily or often broken. The arched 
contour and the cartilaginous portion serve to protect against such 
accidents. A blow or fall upon the nose sideways, however, may drive 
the bones inward and produce deformity, or a powerful force, like the 
kick of a horse, may shatter the osseous arch. The deformity pro- 
duced by such accidents is shocking. The sense of smell is likely to 
be destroyed on account of the damage done to the olfactory nerves. 
Examination under ether will reveal the nature and extent of the 
injury, which is readily apparent. The fact that such accidents are 
liable to produce concussion of the brain should not be lost sight of 
in forming a prognosis. 

Treatment. — Pain, bleeding, oedema, swelling, and emphysema 
of the tissues demand immediate attention to check the haemorrhage, 
relieve the pain, and reduce the swelling. Anodynes and the ice-bag 
(Fig. 83) meet these requirements. Then the fractures must be re- 
duced to as perfect coaptation of the parts as possible, since nasal 
deformity, above all others, influences the business and social in- 
terests of the patient. The pure-silver Eustachian catheter can be 
bent to the proper shape and inserted beneath the depressed bones 
to elevate them to their correct level, while the fingers of one hand 
support them from without and assist in nicely adjusting them. If 
restored to their normal relations they remain so, since there is no 



294: FOEEIGN BODIES IN THE NOSE. 

muscular contraction to again displace them. Union usually takes 
place rapidly. 

Congenital Defoemities of the Nose. 

These are exceedingly infrequent occurrences. If a deformity 
consist of an impervious membrane of the posterior nares it must 
be perforated to establish nasal respiration. 

Foeeign Bodies in the Nose. 

The nose, like the ear, is a favorite receptacle for foreign bodies 
introduced by children and the insane. Beans, peas, pebbles, etc., 
are not infrequently found lodged in these cavities. The act of vom- 
iting occasionally forces the ejected matter into the post-nasal space. 
Bodies inserted into the nostrils are generally located near the vesti- 
bule in the inferior meatus and are readily seen on inspection. Sneez- 
ing, lacrymation, nasal obstruction and discharges are the symptoms 
that point toward the invader. Berries so absorb the serum and swell 
that their increased calibre and the tumefaction of the mucous mem- 
brane occlude the offended nostril. Unless the body is removed it 
provokes inflammation and ulceration, with frontal and facial neu- 
ralgia and a purulent discharge more or less discolored with blood. 
The inflammatory process may extend backward to the post-nasal 
space and to the opposite nostril, compelling oral respiration and 
causing loss of smell and impairment of hearing from involvement 
of the Eustachian tube. Decomposition of the retained secretions 
causes a fetid odor and the occasional expulsion of cheese-like masses. 

If the obstructing body has been crowded or snuffed backward 
into the middle portion of the meatus, it may be shielded from view 
by the swelled turbinal or by a covering of the discharges. The secre- 
tions should be soaked up by the careful application of absorbent 
cotton on the carrier. This is better than to syringe or spray the 
nose, for there is less liability of forcing the body farther out of reach. 
After drying the cavity a 10-per-cent. solution of cocaine is applied 
to the tumefied turbinal, so as to contract it and afford a view of the 
whole interior of the cavity. The probe will then detect any alien 
substance. 

Treatment. — Foreign bodies should be removed as early as pos- 
sible to prevent serious consequences. This can generally be accom- 
plished by angular forceps (Fig. 173). They should be applied with 



LARY^E IN THE NOSE. 295 

care not to crowd the body farther inward. It is best not to close 
the jaws of the instrument until one is certain that it embraces the 
body a little beyond its centre, otherwise it is likely to slip off, and 
in doing so propel the body still farther from view. In the case of 
a berry of a plant, like the bean, that has become softened and en- 
larged bj the absorption of moisture, a sharp hook like the one found 
in the authors middle-ear case (Fig. 70) can be made to imbed itself 
in the substance of the body and glide it out of the canal. In some 
instances a blunt hook, the snare, and mouse-tooth forceps offer de- 
cided advantages. 

Maggots in the Nose. 

This is a condition rarely found except in tropical climates. The 
eggs of flies are deposited in or about the nares, maggots are hatched, 




Fig - . 173. — Hartmann's forceps. 

and destruction of the soft tissues and even of the nasal bones ensue. 
M. A. Goldstein reported having removed over 300 larvse from the 
nose of a patient who had been infected by a blow-fly (The Laryngo- 
scope, December, 1897). Itching, crawling, gnawing sensations and 
intense pain are experienced. A bloody, purulent discharge of fetid 
character appears. The intense inflammation may invade the sur- 
rounding structures, causing redness and oedema of the face and men- 
ingitis, with convulsions, coma, and death. 

Diagnosis. — Inspection readily reveals the cause of the trouble. 

Treatment. — Chloroform is the most efficient remedy. Inhala- 
tion may be sufficient to destroy the larva?; if not, it should be in- 



296 LAEV^ IN THE NOSE. 

jected into the nose after enough has been inhaled to prevent pain. 
This is made to syringe out all the maggots and effectually empty the 
cavities. William Scheppegrell found that oil freely sprayed into the 
nostrils killed the larvae (The Laryngoscope, February, 1898). After- 
treatment should be attended to according to the condition present 
until the health of the membrane is restored. 



CHAPTER XXY. 
DISEASES OF THE ACCESSORY CAVITIES OF THE XOSE. 

Inflammation of the Antrum of Highmore, or 
Maxillary Sinus. 

This disease occurs sometimes as a complication of acute rhinitis, 
and if severe is accompanied by a sense of uneasiness or pain and 
tenderness in the antral, orbital, and frontal regions. These symp- 
toms are more common when there is obstruction to the outward flow 




Fig. 174. — Transverse vertical section through the nasal fossae and 
maxillary antra. 1. superior turbinated body united to the middle turbi- 
nal; 2, polypoid growth from the shelving outer wall of the fossa; 3, in- 
ferior turbinated bodv: 4. tumor in the maxillary antrum. 



of the secretions. If the disease does not subside coincidently with 
the subsidence of the rhinitis, a chronic suppuration results, or em- 
pyema. It may arise as a sequel to diseases of the teeth, especially 
the first and second molars, or in connection with the eruptive fevers 
and syphilis (Fig. 179). 

(297) 



298 



INFLAMMATION OF THE M AXILLAE Y SINUS. 



This affection is generally unilateral. Examination reveals a 
purulent discharge in the middle nasal meatus and its foul odor is 
noticed by the patient, showing the difference between this and ozama, 
in which the sense of smell is destroyed. Empyema of long standing 
affects the general health to such a degree that a constitutional dis- 
turbance is readily apparent, and tumors sometimes develop (Figs. 
174 and 175). 

Diagnosis. — This is aided by the use of a 10-per-cent. solution 
of cocaine in the nose to contract the turbinals. If a rhythmic pulsa- 
tion is seen in the pus lying in the middle meatus, antral suppura- 




Fig. 175. — Transverse vertical section of the nasal fossae. 1, ethmoid 
cells. 2, deflection and spur of the nasal septum, probably the result of a 
fracture separating the two plates of which this bone consisted; the con- 
sequent pressure on the left turbinals has caused their atrophic condition. 
3, tumor in the antrum of Highmore. 



tion is suggested. The pus should be removed and observation made 
to determine if it reappear from the antral cavity, issuing from below 
the middle turbinal. Pressure over the maxillary sinus or tapping 
upon a tooth may reveal tenderness. If hydrogen dioxide (peroxide) 
can be injected into the antrum through the opening beneath the mid- 
dle turbinal, the usual effervescence will disclose the presence of pus, 
and is likely to cause pain. In exploring the antrum some operators 



TREATMENT OF INFLAMMATION OF THE MAN1LLAEY SINUS. 



299 



prefer to enter the cavity through the socket of a tooth, which may 
need to be sacrificed for this purpose, while others open the wall of 
the inferior meatus. Still others perforate the thinner wall of the 
middle meatus, under cocaine, going outward and downward to avoid 
the orbit. Then, the author's aspirator (Fig. 6S) may succeed in 
sucking the pus from the cavity. The patient is instructed to make 
a continuous effort, as in pronouncing the consonant part of h, so 
as to elevate the palate and close the post-nasal space. Then the air- 
pump is manipulated, to prove the presence of pus. 

Prognosis. — This is not an inspiring one. The nature of the 




Fig. 176. — Transverse vertical section through the maxillary antra, a. antra, 

of Highmore; 6, very thin alveolar process, allowing the teeth to 

nearly penetrate the floor of the antra. 



case is unfavorable for spontaneous resolution, and if the bone is 
necrotic a tedious time is to be expected. 

Treatment. — As a complication of acute rhinitis, the treatment 
for the latter is indicated. If the mouth of the sinus is closed it 
should be cleansed with the antiseptic sprays, mentioned in Chap- 
ter XVIII, with diluted hydrozone, and then moistened with a cocaine 
solution to contract the tissues and open the hiatus. If there is much 
pus in the antrum or if it is inspissated, it is not an easy matter to 
evacuate and cleanse the sinus through the ostium maxillare. The 
opening is so small that it may be necessary to penetrate the bone. 
Some operators, like the late Moses Gunn. make a crucial incision 



300 



OPERATIONS ON THE MAXILLARY SINUS. 



in the cheek, and perforate through the canine fossa, but it is better 
to penetrate through the alveolus of a tooth, especially if it prove 
to be the exciting cause of the trouble (Figs. 176 and 177). 

The weight of argument and experience is in favor of entering 




Fig. 177. — Transverse vertical section through the maxillary antra, 
showing on either side that an operation to open the antrum through the 
socket of a tooth would result in penetrating the nasal cavity instead of 
the antrum of Highmore. 

the sinus through the nose, just below the natural opening. The 
cannula and trochar (Fig. 178) are best adapted for this purpose, for 
the cannula can be left in position until the cavity is thoroughly 
cleansed and medicated. The after-treatment should be conducted 




Fig. 178. — Cannula and trochar. 



similarly to the medicinal treatment detailed for middle-ear suppura- 
tion. 

Miscellaneous. — Phlegmonous inflammation of the antrum is a 
very rapidly fatal form of inflammation. 

Tumors of the antrum are exceedingly rare, but require extirpa- 
tion through the anterior wall. Daly (New York Medical Journal, 
Xovember 10, 1894) urges early operation in antral disease to prevent 



ETHMOID DISEASE. 301 

the transformation of a benign growth into a malignant one (Figs. 
174 and 175). 

Ethmoid Disease. 

An inflammation of the nasal membrane sometimes extends into 
the ethmoid cells (Fig. 179), the membrane of which, like that of the 
mastoid cells, lines the osseous cavities and serves as a periosteum. 
Hence an inflammation of this membrane is readily communicated to 
the bony walls themselves, resulting in caries and necrosis. Pain is 
referred to the root of the nose and the orbital and temporal regions. 
The disease may extend so as to produce a bulging prominence be- 
tween the eye and the root of the nose, and the eyeball may protrude 
abnormally. In a girl of 17 years, now under treatment (Fig. 185), 
the arch of the nasal bones was widened, the vault of the nares was 
filled with mucous polypi, and the flow of the muco-purulent dis- 
charge was enormous, necessitating the carrying about of a bundle of 
cloths instead of a handkerchief. There were also adenoids in the 
vault of the pharynx, hypertrophied tonsils, and chronic suppura- 
tion of both middle ears. The polypi, adenoids, and tonsils were re- 
moved, but the polypi were reproduced with mushroom-like rapidity. 
The ethmoid cells were opened up and curetted, and she is improv- 
ing satisfactorily, the discharges from the ethmoid cells and ears 
having ceased. 

Diagnosis. — The antrum of Highmore is often involved coin- 
cidently. and it is sometimes difficult to make a differential diagnosis 
between the two. However, the pain in ethmoiditis is referred to 
the root of the nose and back of the eye, and the eye symptoms help 
to clear up the uncertainty. The discharge is generally seen where it 
occurs in antral suppuration, but the smell, in this disease, is more 
likely to be impaired or lost. 

Prognosis. — When ethmoiditis is a simple concomitant of acute 
rhinitis it subsides together with the principal disease. Suppuration 
is a serious condition, for it may invade the orbit or extend to the 
cerebral meninges. 

Treatment. — Antiseptic, detergent washes already given in the 
first chapter of Part II— hydrozone, etc. — must be employed for 
cleansing purposes. All polypi should be removed and then the 
curettes shown in Fig. 90 can be used to scrape out carious and 
necrotic tissue. If the middle turbinate body is too large to admit 
of proper observation and manipulation, it must be removed, as already 



302 



ETHMOID DISEASE. 




Fig. 179. — Longitudinal vertical section (actual size) through the nasal 
and accessory cavities. 1, right termination of the left frontal sinus; 2, 
right frontal sinus; 3, probe extending from the right frontal sinus through 
the infundibulum into the right nasal fossa; 4, ethmoid cells; 5, large 
opening into the maxillary sinus; 6, anterior antrum of the sphenoid bone: 
7, posterior sphenoid antrum; 8, middle nasal meatus; 9, inferior meatus; 
10, inferior turbinated bone; 11, probe extending through the nasal duct. 
(Author's specimen.) 



SPHENOID DISEASE. 303 

described. The anterior ethmoid cells are in communication with this 
turbinal; hence the advantage of its excision. After-treatment is the 
same as for antral suppuration. 

Polypi sometimes take their origin from the ethmoid cells, pro- 
ducing pressure on the surrounding structures. The result is apparent, 
especially in the increased breadth of the nose and the prominence 
of the eyes (Fig. 185). Osteomata produce like appearances. The 
treatment for growths in this locality consists in extirpation. 

Sphenoid Disease. 

It may be observed that I have departed from the custom of add- 
ing "al" to the adjectives ethmoid and sphenoid. This is because it 
is ctymolpgically correct to do so; it is in keeping with the American 
tendency to brevity and terseness, and in conformity with the com- 
mon use of the corresponding term "mastoid"' instead of "mastoidal/' 
These terms are Greek adjectives merely transferred into English, and 
are not rendered more perfect by additional terminations. 

Sphenoiditis occurs as a complication or sequel of inflammation 
of the nasal accessory cavities (Fig. 179) and of meningitis. The 
symptoms are not pathognomonic and this affection is difficult to 
differentiate from disease of the ethmoid cells. The pain is deeply 
seated, the discharge empties into the throat, and dimness of vision, 
strabismus, and prominence of the eyeball are symptoms character- 
istic of this disease. 

The prognosis is unfavorable on account of the tendency to in- 
vade the cranial cavity (Fig. 180). 

Treatment. — The methods already described for diseases of the 
accessory cavities are applicable here. If it should become necessary 
to open and curette the sphenoid sinus (Figs. 179 and 180), the in- 
strument should be passed over the middle turbinal, backward and 
upward, until it enters the lower part of the cavity. The sinus can 
be opened through its under wall, also by perforating through the 
pharyngeal vault immediately back of the posterior nares. Subse- 
quent treatment has been indicated in treating of the other sinuses. 

Tumors are rare in the sphenoid sinuses, but if they produce 
blindness or other serious symptoms they must be removed. 

Diseases of the Feoxtal Sixtjses. 

Inflammation of these cavities (Figs. 179 and 180) occurs mostly 
from extension of rhinitis. It is not to be expected under the 



301- 



DISEASES OF THE FROXTAL SINUSES. 



twentieth year, since these sinuses, being developed from the ante- 
rior ethmoid cells, are not formed earlier. Acute inflammation is 
characterized by a severe, continuous, frontal headache and pain 





Fig. 180. — Longitudinal vertical section (natural size) through the 
nasal and accessory cavities. 1, left frontal sinus; 2, termination of the 
right frontal sinus; 3, crista galli; 4, cribriform plate of the ethmoid bone; 
5, perpendicular plate of the ethmoid; 6, part of the anterior sphenoid 
antrum; 7, posterior sphenoid antrum; 8, vomer; 9, palate bone. (Au- 
thor's specimen.) 



TREATMENT OF DISEASES OF THE FRONTAL SINUSES. 305 

about the eyes. There is tenderness over the sinuses on percussion, 
and on pressure beneath the supra-orbital ridge. Nausea and vomit- 
ing are occasionally present. The pain may not be due entirely to 
the swelling of the mucous membrane lining the cavities, but to the 
loss of the natural air-pressure, for I have observed that the pro- 
pelling of air impregnated with a nebula of camphor-menthol into 
the sinuses gave decided relief. 

When the infundibulum, or passage between the nasal and frontal 
cavities (Fig. 179), becomes clogged, the retained secretions, mucus 
or pus, will cause great pain. The pressure may be sufficient to 
cause absorption of the osseous partition separating these sinuses, or 
bulging may take place downward and outward so as to encroach and 
press upon the eyeball. 

Suppuration of the frontal sinuses is an infrequent disease. The 
pus can be seen in the middle meatus under good illumination, flow- 
ing downward from the region of the sinus-opening. It should be 
wiped away and the area watched to see the source of the discharge. 
If the pus break through the posterior wall of the sinus, there are 
symptoms of brain-compression, drowsiness, headache, stupefaction, 
etc. This complication induces purulent meningitis. 

The symptoms point quite distinctly to the seat of the trouble, 
and are not so obscure as in sphenoiditis. The electric lamp and con- 
denser of Heryng are useful in making diagnoses in this class of dis- 
eases. Transillumination of the frontal sinus is accomplished by ap- 
plying the lamp to the lower border of the supra-orbital ridge and 
inner angle of the orbit in a dark room. In health the sinus is illu- 
minated up to the superciliary ridge, but in case of the presence of 
pus it is dark. 

Treatment. — The first indication is to subdue the pain. If the 
inflammation occur in the course of acute rhinitis the treatment for 
that is appropriate and effective here. An application of a 10-per- 
cent, solution of cocaine to the sinus-opening may so contract the 
swollen tissues as to open the duct, give exit to the pent-up secre- 
tions, and relieve the pain. The detergent, antiseptic sprays given 
in Chapter XVIII are useful in this affection. After cleansing the 
cavities by sprays and having the patient repeatedly blow his nose, 
great relief is afforded by throwing a nebula of a 10-per-cent. solution 
of camphor-menthol in lavolin or benzoinol into the nostrils, with the 
air-current directed toward the naso-frontal duct. This tends to 
evacuate any retained secretions and to restore the normal air-press- 

20 



306 TEEATMENT OF DISEASES OF THE FBONTAL SINUSES. 

lire in trie sinuses, besides medicating the remote membrane as ordi- 
nary treatment fails to accomplish. 

In the acute stage an ice-bag (Fig. 83) is indicated to subdue 
and avert the inflammation. It should be applied over the frontal 
j)rotuberances and the root of the nose. If this should not afford 
relief, or if it prove irritating, hot fomentations may be substituted. 
Any obstructing hypertrophies or tumors must be removed, as pre- 
viously described. If the discharge contained in the sinuses cannot 
be liberated by opening the naso-frontal duct with air-pressure, co- 
caine, or a probe, it may be necessary to penetrate the sinus directly, 
near the internal angle of the orbit, at which point the cortex is quite 
thin. 

This procedure is similar to that which has already been detailed 
for opening the mastoid antrum and removing the diseased contents. 
Tumors of the frontal sinuses are treated on the principles already 
laid down for tumors of the other accessory cavities. 



CHAPTER XXYI. 
RELATED DISEASES OF THE EYE AND NOSE. 

Foe many years it has been recognized that diseases of the eye 
and of the nose were often associated and interdependent. In cer- 
tain cases pathological conditions originate in the nose and extend, 
by continuity of tissue or by migration of morbific germs, to the eye. 
Occasionally the reverse process occurs. More recently reflex ocular 
disturbances arising from nasal affections have received attention. 

"When one considers the close relationship existing between the 
eye and the nose and its adjoining cavities, it is not surprising that 
morbid conditions of these parts are closely related. The mucous 
membrane of the eyeball and lids is continuous with that lining the 
lacrymal sac, the nasal duct, and the nasal and connecting cavities 
(Fig. 181). The eye is in close proximity to these cavities, and the 
blood- and nerve- supplies of the nose and eyes are intimately con- 
nected with each other. The nasal duct is the drainage-canal of the 
eye, through which the surplus moisture of the latter is emptied into 
the nose. Hence, organisms inhabiting the nose or its accessory 
sinuses and antra may migrate through the nasal duct to the eye 
(Fig. 182), and, conversely, disease-germs that lodge in' the eye may 
pass through the lacrymal sac and the nasal duct to the nasal fossa, 
there to set up their pathological processes. 

In health there is a free communication between the nose and 
the eye; so much so that inflation of the nasal cavities may cause the 
air to pass through the nasal duct, the lacrymal sac, and canaliculi to 
the eye. Indeed, the author remembers to have seen the loose areolar 
tissue about the eye, the side of the nose, and the upper part of the 
cheek made greatly emphysematous after a nasal inflation, due to 
rupture of the lacrymal sac. The swelling occasioned no inconveni- 
ence, and it subsided in a few hours. This case illustrates the ease 
with which morbific material may be propelled from the nasal cavity 
through the patulous nasal duct to the eye by the acts of sneezing 
and inflation of the nasal fossa? by the Yalsalvan experiment and by 
blowing the nose. From this cause may originate inflammatory affec- 
tions of the lids, cornea, or sclera. 

(307) 



308 



BELATED DISEASES OE THE EYE AXD XOSE. 



In order to set forth fairly the present status of opinions on this 
subject among ophthalmologists we will refer to the experiences of 
several authors. 

W. F. Mittendorf says: "Inflammatory 'conditions of the lining 
membrane of the nose are, perhaps, the most frequent of all the causes 
of inflammatory actions in the tear-passages. How often do we not 
see diseases of the conjunctiva or cornea, especially those that 
are accompanied by lacrymation, followed by inflammation of the 




Fig. 181. — Dissection showing nasal duct and its relations. 1, inferior turbi- 
nate bone; 2, nasal duct and valves; 3, middle turbinate body; 4, 
lacrymal sac; 5, laerymal canaliculi and their orifices. 



Schneiderian membrane; and, on the other hand, mild forms of 
conjunctivitis generally accompany catarrhal inflammation of the 
nose or the tear-sac." 

Gr. E. de Schweinitz, in his work on the eye, 1893, says: "Dis- 
eases of the lacrymal sac are rarely primary. In nearly every case 
of disease of the lacrymal sac and of the lacrymo-nasal duct morbid 
conditions of the nasal chambers and of the naso-pharynx are pres- 



RELATED DISEASES OE THE EYE AXD XOSE. 



309 



ent. Although it might seem natural that conjunctivitis, and espe- 
cially purulent conjunctivitis, should cause lacrymal disease, this is 
by no means frequently the case. Conjunctivitis and blepharitis, so 
often accompanying diseases, follow rather than cause the lacrymal 
affection. Obstruction of the duct and diseases of the sac are sequels 
of measles, scarlet fever, and especially small-pox, because these exan- 
themata are accompanied by inflammation of the nasal mucous mem- 
brane.^ 

George M. Gould says that in the vast majority of cases of related 




Fig. 182. — 1, middle turbinated body turned aside and held by a 
hook; 2, nasal duct and valves; 3, canal leading to the maxillary and 
frontal sinuses; 4, inferior turbinated body showing location of the mouth 
of the nasal duct in the cul-de-sac. 



affections of the nose and eye the nose is the point of departure of 
the morbific process, the eye more seldom setting up disease in the 
nose. 

Bresgen observes that the nose is infrequently invaded in con- 
junctivitis, while the eye is implicated in coryza. 



310 BELATED DISEASES OF THE EYE AND NOSE. 

Thomas F. Rumbold, in 1886, emphasized the importance of nasal 
catarrh as a cause of eye affections. 

Griihn reports thirty-eight cases of dacryocysto-blennorrhoea as- 
sociated with hypertrophy of the turbinals, spurs and deflections of 
the nasal septum, and atrophic rhinitis and pharyngitis. He attributes 
the lacrymal troubles to the nasal diseases. 

W. Franklin Coleman, of the Chicago Post-graduate Medical 
School, expressed his views in a private letter to me on February 4, 
1898, to the effect that in nasal inflammation, whether independent 
of or accompanied by hay fever, it is common to find the ocular con- 
junctiva hypersemic or inflamed. Many cases of epiphora are not due 
to stenosis of the lacrymal passages, but to a nasal disease. Purulent 
inflammation of the lacrymal sac has its origin, as a rule, in a nasal 
disease, and rarely in an ocular affection. The extension of rhinitis 
to the nasal duct is followed by stenosis, decomposition of the. con- 
tents of the sac, and suppuration. Asthenopia, occasionally, is not 
relieved by correction of refractive or muscular errors, neurasthenia, 
or other constitutional faults. In these cases relief comes through 
attention to the etiological factors: nasal diseases. Phlyctenular 
conjunctivitis and keratitis, though often essentially due to malnu- 
trition, are so frequently accompanied by rhinitis and eczema of the 
lower lid and face that we may assume the nasal disease to be a 
causative factor of the ocular. Yet, in some cases the rhinitis seems 
to follow the excessive lacrymation, just as the eczema of the lid and 
face follows the ocular disease and its attendant epiphora. 

E. W. Seiss has reported several cases of closure of the nasal 
mouth of the lacrymo-nasal duct caused by unskillful use of the cau- 
tery. The effect on the drainage of tears is evident. 

A number of illustrative cases are reported in the "American 
Year-book of Medicine and Surgery" for 1897. Among them is a 
case cited by Panas, in which there was double purulent dacryoadeni- 
tis, coincident with a severe tonsillitis and muco-purulent nasal ca- 
tarrh. Ramsey, in treating of lacrymal obstructions, advocates the 
necessity of examining the nasal fossae, of treating inflammatory or 
hypertrophic conditions found, and of investigating for a syphilitic 
history. 

T. K. Hamilton found eye diseases in 51 out of 106 cases of post- 
nasal vegetations. In 6 of these there was blepharitis, in 7 follicular, 
in 16 granular, and in 22 catarrhal conjunctivitis. 

John Dunn believes that in the vast majority of cases of chil- 



BELATED DISEASES OF THE EYE AND NOSE. 311 

dren suffering from phlyctenular troubles there will be found a coin- 
cident rhinitis, and behind this unhealthy adenoid vegetations. 

Samuel G. Dabney has seen obstinate cases of ciliary injection and 
lacrymation disappear immediately on removing a septal spur which 
was pressing against a turbinated body. Photophobia and asthenopia 
are occasionally caused by hypertrophic rhinitis. More grave diseases, 
such as glaucoma and organic affections of the optic nerve, have also 
been attributed to nasal influence. 

D. B. St. John Koosa, in his book on the eye, in treating of 
lacrymal catarrh, says that in a large proportion of cases it is a purely 
catarrhal affection, produced by the same causes that bring on catarrh 
in other parts of the naso-pharyngeal tract, colds in the head, and 
catarrhal conjunctivitis. 

Influenza has given rise to orbital cellulitis, and out of three such 
cases recently two have died of the influenza. 

Nieden maintains that phlyctenular keratitis almost invariably 
takes its origin from a disease in the nose. 

Puech observed instances of lacrymation occasioned indirectly by 
decayed stumps of teeth which set up chronic inflammation of the 
antrum of Highmore and the nasal fossa, thence extending upward 
into the nasal duct (Fig. 179). 

Herman Knapp records an instance of lupus extending from the 
nasal fossa toward the lacrymal canal, followed by dacryocystitis. 

Bresgen lays stress on the causal relation of nasal disease to strict- 
ure of the lacrymal canal, and insists that every lacrymating patient, 
even when he first visits an ophthalmic surgeon, ought immediately 
to be referred to a rhinologist for a scientific examination, and for 
eventual nasal treatment. 

Fischer attributes cases of chronic conjunctivitis, trachoma, 
iritis, keratitis, and glaucoma to ozama; and gonorrhceal ophthalmia 
has been traced to infection by way of the nose and the lacrymal 
canal. 

Guenod states that the pneumococcus, which is a normal resident 
of the upper, anterior air-passages, has been found in conjunctivitis, 
dacryocystitis, deep ulcers of the cornea, and in panophthalmitis. 

Guttman has reported a case of diphtheric conjunctivitis in which 
true diphtheric bacilli were found occurring during an attack of 
measles, and which was complicated by corneal abscess, purulent cellu- 
litis of the lids and cheek, and extension of the false membrane to 
the nose and throat. Antitoxin was injected early, but had no in- 



312 KELATED DISEASES OF THE EYE AND NOSE. 

fluence whatever in staying the progress of the disease or in averting 
a fatal termination. On the other hand, Coppez and Funk speak, 
from a large experience, in the highest terms of the efficacy of serum- 
therapy in the treatment of diphtheric conjunctivitis. 

An appearance of excessive lacrymation may be caused by an 
obstruction to the passage of tears into the nose, due to ethmoid dis- 
ease or pressure of a nasal polypus or other growth on the nasal duct. 
On account of this the tears flow over the lid and cheek (epiphora). 
Ethmoid disease may produce sufficient pressure to increase the dis- 
tance between the eyes, causing the globes to protrude, and giving 
the appearance known as frog-face (Fig. 185). These variations in 
the anatomical relations of the bones of the orbit and the recti mus- 
cles may produce disturbances of the functions of the eye, such as 
strabismus and astigmatism; or overdevelopment of the sphenoid 
bone may produce pressure on the optic nerve and impair or destroy 
its functions. Thus it will be seen that a growth in the nasal fossa, 
exceeding the natural limit of the cavity, may be the cause of serious 
ocular disturbances. 

Hansell referred acute, double optic atrophy in a young man to 
a purulent disease of the ethmoid and sphenoid cavities. 

Reflexes. — In 1882, and later, Hack called attention to the prob- 
ability of reflex ocular symptoms origin ating in pathological condi- 
tions of the nasal cavities. He also observed the causative relation 
of inflammatory conditions of the Schneiderian membrane to sick 
headache, neuralgia, cough, asthma, pain and swelling of the eyelids, 
and that, while the ordinary treatment for these latter affections was 
ineffective, they yielded to measures which restored the pituitary mem- 
brane to its normal condition. 

Eecently M. Georges Laurens has pointed out that more extended 
experience has added a large number of morbid phenomena to those 
that Hack regarded as taking their departure from nasal affections. 
Among these are epilepsy, vertigo, nightmare, sensations akin to 
those produced by a foreign body in the eye, heat, pricking, injection 
of the conjunctival blood-vessels, amblyopia, amaurosis, and photo- 
phobia. 

Numerous illustrative examples could be cited in which reflex 
irritation of branches of the fifth nerve occasions ocular disturbances, 
such as conjunctival irritation and lacrymation. When these symp- 
toms are owed to diseased conditions of the inferior turbinated body 
they have disappeared on cauterization of the turbinal. On the other 



BELATED DISEASES OF THE EYE AND NOSE. 313 

hand, Alt reports a case of optic neuritis consequent upon cauteriza- 
tion of the turbinals in a syphilitic patient. "The reflex troubles of 
motility consist of blepharospasm, strabismus, mydriasis, and asthe- 
nopia; the trophic disturbances consist in congestion of the con- 
junctiva, iritis, and glaucoma, while exophthalmic goitre may, in some 
instances, be regarded as a condition associated with disease of the 
nasal mucous membrane. Contraction of the visual field has been 
observed by several practitioners. The affection of the eye is always, 
in accordance with the law of unilaterality, on the same side as the 
disease of the nose, though, in accordance with the law of symmetry, 
in some instances both eyes are affected, and in accordance with the 
law of intensity the eye ]3rimarily affected is always the most severely 
attacked." ("Year-book of Treatment," 1897.) 

The nasal diseases that are the most prolific of ocular manifesta- 
tions are chronic hypertrophic rhinitis, especially when there are con- 
tact, pressure, and even adhesions of the nasal septum and turbinals; 
acute rhinitis, inflammation of the membrane lining the sinuses con- 
necting with the nose, ulceration of the nasal membrane, ozama, and 
polypoid growths. "The reflex conditions that may be excited have 
reference to the sensibility of the eye, to the character of the secre- 
tions, to motilit} r , and to trophic and vasomotor disturbances.'*' 
(Laurens.) 

The effects of nasal hypertrophy, pressure, irritation, and con- 
sequent ocular and other disturbances were well exhibited in a some- 
what exaggerated case in the author's practice. A musician, 22 years 
old, presented symptoms of amblyopia and chronic non-suppurative 
inflammation of her middle ear, with subjective noises. The morbid 
manifestations were confined to her left eye and ear. The results 
of examination of these organs were negative, but there was an osseous 
adhesion between the left middle turbinated body and the septum 
nasi, and hypertrophy of the inferior turbinal of the same side. The 
patient suffered from frontal headache; and a most peculiar and in- 
teresting incident was a loss of power and uncomfortable sensations 
of her left arm, together with pain in her left side. The asthenic 
condition of her arm, combined with the impairment of vision, com- 
pelled the young lady to discontinue her piano-playing. After thor- 
ough electrocauterization of the inferior turbinal and the removal of 
the osseous synechia, not only did the eye and ear disturbances sub- 
side, but the neurasthenic symptoms referable to the left arm and 
side also vanished. Normal sight and hearing were restored, the 



314: RELATED DISEASES OE THE EYE AXD XOSE. 

tinnitus anrium ceased, the headaches disappeared, and the power and 
natural sensibility of the arm returned. 

Henry D. Noyes, in his work on the eye, relates the case of a 
medical friend who suffered from asthenopia, headaches due to ex- 
cessive strain of accommodation, heat at the vertex of the head, in- 
somnia, facial neuralgia following use of the eyes, and intense photo- 
phobia — a case of refractive and muscular and general nerve-exhaus- 
tion. There were extreme palpebral congestion and a tendency to 
lacrymation on exposure to light and attempting eye-work. The nasal 
passages were found to be narrow, with a slight protuberance of the 
septum from undue thickening, decided congestion, and tenderness 
on being touched. Anaesthesia by cocaine afforded relief in some 
measure to the eye-symptoms. Examination of the eye, after the 
fitting of glasses failed to afford relief, showed that there was much 
spasm of the extrinsic and ciliary muscles. Sprays, the ingredients 
of which were not mentioned, afforded relief. The patient was an 
asthmatic. After removal of the thickened portion of the septum 
with a saw, marked improvement took place, and within four months 
the patient laid aside his glasses and was restored to a condition of 
comfort. 

Galezowski has seen persistent lacrymation caused by slowly- 
growing exostoses of the nasal cavities. 

S. S. Bishop, of Pennsylvania, observes that discomfort of the 
eyes and lids and vasomotor disturbances are sometimes the reflex 
effects of diseases of the nasal mucous membrane. He lays especial 
stress on spurs of the septum nasi and hypertrophy of the turbinate 
bodies as causes of these troubles. 

Cheatham is authority for three cases of asthenopia accompanied 
by other ocular symptoms. In each instance the ciliary weakness 
was found to be dependent upon local nasal trouble, such as catarrh,, 
polypi, obstructions from deflected nasal septum, or engorged tissue. 
Ocular relief and strength immediately followed upon a cure of the 
nasal abnormality. 

Many sufferers from hay fever are attacked with itching of the 
lids, lacrymation, injection of the conjunctival vessels, and photo- 
phobia during the season of suffering. The first attacks of this dis- 
ease are likely to be announced by the appearance of itching and 
suffusion of the eyes. 

Gradle speaks of a periodic discomfort allied to hay fever, or 
co-existing with conjunctival lesions, at first of follicular enlargement,. 



TEEAT3IEXT OF EYE DISEASES DUE TO NASAL AFFECTIONS. 315 

and finally of a formation of large, flat, yellowish, follicular grannies 
which disappear in winter, arising from nasal affections, and he adds 
to these acute congestion of the lids with irritable nose, erysipelatoid 
in character, subject to recurrence and lasting from two to six days. 

Diseases of the eye are sometimes responsible for pathological 
states of the nose. Of 315 cases of functional nervous affections ex- 
amined by Miles with reference to eye-strain, 107 presented nasal 
symptoms, such as frequent sneezing, epistaxis, and annoying sensa- 
tions referable to the nasal fossa?. Nearly all of these cases had errors 
of refraction. After relieving the ocular irritation by correcting the 
ametropia with proper lenses the nasal symptoms diminished or dis- 
appeared. This was particularly true of those cases characterized by 
asthenopia and headache. Ocular disturbances that cause a profuse 
flow of tears give rise to nasal hydrorrhcea and chronic rhinitis. 

Treatment.- — When ocular disturbances are suspected of being- 
caused or perpetuated by diseases of the nasal cavities, — for example 
venous stasis, stenosis, or reflex irritation, — we may often be able 
to demonstrate the correctness of our conclusions by the application 
of a 10-per-cent. solution of cocaine to the diseased area. If it re- 
lieve the ocular symptoms, the line of successful treatment is indi- 
cated; but one had best bear in mind the case recorded by Marckwort, 
in which glaucoma followed a prolonged application of cocaine in 
the nose. Moreover, the author has met with cases in which the 
secondary effect of cocaine on the nasal mucous membrane was that 
of paresis of the blood-vessels, engorgement and complete nasal steno- 
sis, with intensified symptoms of hay fever. 

YThen obstruction to the free drainage of the tears through the 
nasal duct into the nose depends upon a disease of the nasal fossa, 
the latter must receive prompt treatment, as laid down in the fore- 
going chapters. In all such cases the nasal cavities should be thor- 
oughly examined without delay, and in many the nasal treatment 
alone will suffice to establish a normal condition. But the disease 
may have progressed so far as to call for treatment addressed to the 
lacrymal drainage-canal itself. Stenosis, fibroid adhesions, etc., may 
have produced permanent changes in the nasal duct or the lacrymal 
sac that will require special attention from the ophthalmic surgeon. 
However, tentative treatment should be instituted first, and it may 
succeed in obviating the necessity for surgical interference. 

The lacrymal sac can be emptied of pent-up secretions by gentle 
pressure, and the eye should be washed clear of them by a 2-per-cent. 



316 TREATMENT OE EYE DISEASES DUE TO NASAL AFFECTIONS. 

solution of boric acid in distilled water. If an astringent lotion is 
desired, sulphate of zinc can be added in the proportion of 2 grains 
to the ounce of the solution. The manipulation and medication are 
effected in the following manner: The surgeon's finger is made to 
exert pressure on the sac from below and toward the eye, while the 
patient's head is tilted backward and toward the opposite side. After 
the sac is emptied of secretions the boric solution is made to rest in a 
little pool over the canaliculi while the sac is emptied as before, with 
the- result that the solution enters the evacuated sac and medicates 
the nasal duct. This simple treatment, combined with proper meas- 
ures addressed to the nasal disease, will cure a large proportion of 
these cases. 

When this method proves ineffectual, the orifice of the canaliculus 



Fig. 183. — Lacrymal knife. 

(Fig. 181) must be enlarged. This can be done with the iris-scissors 
or the lacrymal knife (Fig. 183), which is introduced with the sharp 
edge directed toward the eye, cutting the punctum open perpendicu- 
larly toward the palpebral fold for a distance of about one-sixteenth of 
an inch (two millimetres) or more. The lower canaliculus is the one 
that is generally opened. Then the solutions just mentioned, or silver 
nitrate, 2 to 5 grains to the ounce of water, should be used until 
either a cure is effected or it is demonstrated that there is a stricture 
of the duct. In the latter case the smaller probes of Bowman may be 
gently employed to dilate the stricture. For further surgical treat- 
ment the reader is referred to works on the eye. 



CHAPTEE XXVII. 
DISEASES OF THE NASOPHARYNX. 

Nasopharyngeal Catarrh. 

Synonyms. — Post-nasal catarrh; rhino-pharyngitis; retronasal 
catarrh; follicular naso-pharyngeal catarrh. 

Pathology. — Xaso-pharyngeal inflammation may be acute or 
chronic, but the acute stage merges into the chronic form, leaving 
a thickening of the mucous membrane, — a proliferation of tissue that 
gives rise to a roughened and granular appearance of the membrane 
and increased secretion from the mucous glands. This is the condi- 
tion most often encountered, but the dry form is not uncommon. 

Etiology. — Sudden and extreme changes in meteorological condi- 
tions, especially in a low, damp climate, are undoubtedly the chief 
exciting causes of this disease. Inhaled dust is another important 
etiological factor; but climatic conditions are of prime importance; 
otherwise, those who live in a dusty atmosphere, but in a warm, high, 
dry, equable climate, would suffer equally with those under the reverse 
conditions. 

This disease is most common in the region of the Great Lakes 
and, indeed, in many other parts of America. Even in Colorado, the 
Mecca of consumptives, this disease prevails. But the soil favors this, 
for it is so light and sandy that the rains percolate through into the 
subsoil in a few hours, leaving on the surface a fine coat of dry dust, 
the toy of the winds and the torment of catarrh. In the Mississippi 
Valley and the Great Lakes Eegion the barometrical and thermomet- 
rical changes are rapid and excessive. The thermometer often falls 
thirty degrees or more in a few hours, and half that much in as many 
minutes. In hot summer-days, with southerly winds, cold waves sweep 
down from the northwest, catching the people in thin clothing, chill- 
ing the skin, and causing internal congestions that naturally attack 
the respiratory passages. The dampness of the atmosphere and the 
prevalence of dust aid in locating the seat of irritation in the most 
exposed air-cavities. After these sudden attacks of cold waves an 
influx of patients usually attests the cold-giving nature of the changes. 
I have found San Francisco no better than Chicago in climatic con- 

(317) 



318 NASOPHARYNGEAL CATARRH. 

ditions. The fogs of the early morning and the cold, penetrating- 
winds of the afternoon, with only a few hours of congenial warmth 
to lure one to don warm-weather attire, present the conditions favor- 
able to the production of naso-pharyngeal catarrh. But the reverse 
of this picture is to be found by a twenty-minute ride across the bay 
to Oakland. There one may doff his overcoat and bask in the balmy 
sunshine of summer, while his neighbors a few miles distant shiver 
in the ocean-winds. But even here we cannot escape the irritating 
dust that plays hide-and-seek with the cilia of the nose. For ca- 
tarrhal patients the climate of Los Angeles or San Diego is preferable 
to that of San Francisco; but even in these delightful gardens of 
America there is no escape from dust. 

The part played by this irritant in the causation of post-nasal 
catarrh is easily understood when we consider the conformation, posi- 
tion, and lining of the naso-pharyngeal cavity. Its shape is such as 
to receive and change the course of the current of air as it strikes 
the vault and posterior wall of the pharynx, and all the dust-laden 
air inhaled through the nose must come in contact with this part. 
The foreign particles not removed by previously impinging on the 
nasal cilia or membrane find lodgment here, and, if sufficient moisture 
has not been absorbed by contact with the nasal chambers proper, 
the secretions of the pharyngeal membrane are taxed to perform this 
function. The resulting storage of dust and the drying of the mem- 
brane, which is devoid of the acute sensibility characteristic- of the 
nose and larynx, and therefore lacks prompt reflex efforts at dislodg- 
ment, tend to excite irritation and consequent inflammation. Other 
predisposing causes of naso-pharyngeal catarrh are discussed in the 
first chapter on "General Consideration of Ear, Nose, and Throat 
Diseases/' 

This disease, like hay fever, is undoubtedly more prevalent in 
America than in European countries. The reasons assigned for its 
prevalence in various parts of this country are sufficient to account 
for this difference. It is not a contagious affection, like epidemic 
influenza, neither can it be termed hereditary, but its universal pres- 
ence is certainly suggestive of a predisposing hereditary influence. 
It is not limited to the frail, but is just as likely to be encountered 
in the robust, and especially in the uric-acid diathesis. 

Symptomatology. — In the early history of naso-pharyngeal ca- 
tarrh the patient notices a sense of irritation in the upper and back 
part of the throat. This provokes attempts at clearing the throat, 



XASO-PHAEYXGEAL CATAEEH. 319 

or hawking, which is irksome to the patient and disagreeable to his 
companions. A sense of constriction and a tired or aching feeling 
is often present, especially while speaking in public. The vocal 
organs weary easily, and the necessary efforts to clear the throat dur- 
ing a lecture or sermon are wearisome to both speaker and audience. 
Clergymen are frequent subjects of this complaint. There is almost 
a universal habit among them of efforts to relieve this irritable con- 
dition of the upper throat. 

Posterior rhinoscopy often discloses a thick, tenacious, light- 
yellow secretion sticking to the posterior wall of the pharynx. On 
removing this discharge the membrane appears very red and rough- 
ened by the formation of granulations. These are round and punc- 
tated or irregular and flat, with broad bases suggestive of particles 
of a filled sponge. Frequently they coalesce, especially at the sides 
of the throat just behind and below the posterior faucial pillars, 
and form a welt extending upward and outward in the direction of 
the Eustachian orifices. These point to the "throat deafness'" so often 
met with in catarrhal climates. The blood-vessels are often engorged 
and tortuous and stand out prominently above the surface of the sur- 
rounding tissues. The Eustachian prominences are swelled and red- 
dened and the orifices constricted or closed. Extension of the in- 
flammation a little farther through the Eustachian openings results 
in tubal catarrh, or salpingitis, and impaired hearing, as already de- 
scribed in the ear division. The pharyngeal, or Luschka's, tonsil is 
sometimes hypertrophied. and in children adenoid vegetations may 
so occlude the vault of the pharynx as to preclude nasal respiration 
(Plate II). Mouth-breathing and its train of evil consequences result. 
The faucial pillars are more or less involved, presenting a swelled, 
infiltrated condition. 

Diagnosis. — There is little likelihood of confounding this affec- 
tion with any other. Adenoid vegetations are confined to the young 
and are easily seen with the rhinoscopic mirror or felt by the finger. 
The same may be said concerning polypi. Syphilis causes sore throat, 
but the characteristic erosions and the history, added to the testimony 
of antisyphilitic remedies, serve to dispel any doubt. 

Prognosis. — Although it is the practice of charlatans to repre- 
sent this disease as being dangerous to life and leading to pulmonary 
consumption, its early history does not confirm such statements. In 
its early stages it yields readily to proper treatment, but after it has 
existed for a number of years it becomes persistently chronic and 



320 TREATMENT OF NASO-PHARYNGEAL CATARRH. 

intractable to nearly all methods of treatment. However, much relief 
can be afforded by hygienic measures, combined with proper cleansing 
and stimulating topical applications and surgical treatment. 

Treatment. — The first object of treatment is perfect cleanliness; 
detergents — such as Dobelfs and Seller's solutions — should be used 
in the form of sprays, both through the anterior nares and throat, 
to dislodge all secretions and crusts that adhere to the nasopharyn- 
geal walls. If these alkaline, antiseptic sprays, that dissolve the 
tenacious secretions and dislodge them in ordinary cases, are not 
sufficient to remove them in this form of catarrh, cotton, twisted upon 
a curved post-nasal cotton-carrier should be used to wipe out all the 
discharges. Then stimulating and tonic sprays should be applied with 
the Davidson or De Vilbiss atomizers. Camphor-menthol in ben- 
zoinol, 5-per-cent. course spray, or a 10-per-cent. solution in the form 
of a nebula, in the hand-dilator (Fig. 19) will afford decided relief. 
A tonic, antiseptic spray is had in eucalyptus in lavolin, 4 per cent.; 
or, as a tonic nebula to be used in the hand-dilator, an excellent prep- 
aration consists of oil of cubebs, 50 parts; pure camphor-menthol, 
10 parts; and lavolin, 40 parts. However, the latter solution must 
not be used in the form of a coarse spray. This and a 10-per-cent. 
solution of camphor-menthol inhaled through the throat and exhaled 
through the nose act as decided stimulants and tonics. It is my 
practice to prescribe for home treatment a 3-per-cent. solution of 
camphor-menthol in lavolin, to be used every morning and night. 
The patient is instructed to throw a sufficient spray of this prepara- 
tion into both^ nostrils and throat to satisfy him that the parts are 
entirely covered with the medicine. The application of this remedy 
proves very grateful and refreshing, especially to public speakers. 
Upon being used at bed-time it remains in contact with the mucous 
membrane during the hours of repose, when no efforts are made to 
clear the nose; so that its action is continuous over a number of 
consecutive hours. All hypertrophied tissues should be destroyed 
with the electrocautery. 

Excessive tobacco-smoking must be interdicted, and those who 
continue to smoke must be instructed that the habit of forcing smoke 
outward through the nose acts as an irritant and aggravates the ex- 
isting condition. The inhalation of dust; irritating gases, like those 
from matches, etc.; exposure to cold and damp and drafts of cold 
air, especially upon the back of the neck and back of the arms; and 
exposure of the feet to cold and wet must be avoided. Animal fibre 



ATROPHIC CATARRH OF THE XASO-PHARYNX. 321 

must be always worn next the skin. Woolen is preferable to silk. 
Cotton and linen must not be used for underclothing. Consisting, as 
they do, of vegetable fibre, they favor rapid evaporation of the per- 
spiration, causing chilling of the skin and contraction of the capillary 
vessels and resulting internal congestion. The diet must be plain and 
nutritious, avoiding an excessive use of meats, sweets, wines, and beer. 

Atrophic Catarrh op the Naso-pharynx. 

This disease usually accompanies the same condition of the nose 
which has already been described, but it may exist independently 
of atrophic nasal catarrh. In the early stage of this affection the mu- 
cous membrane of the naso-pharyngeal space usually appears dry and 
shining. Later, crusts are formed similar to those described in ozama. 
Sometimes quite large patches of these crusts, which adhere closely 
to the membrane and are removed with difficulty, are expelled. They 
are generally of a dirty-white or greenish color and sometimes brown 
or even black. The latter color is usually found where patients are 
exposed to the inhalation of a smoky atmosphere in the neighbor- 
hood of factories, hotels, and buildings in which soft coal is largely 
in use. These crusts sometimes are detached with so great difficulty 
that the patient is under the necessity of inserting his finger into 
the vault of the pharynx and detaching them with his finger-nail. 

The pathology and etiology of this disease are the same as for 
nasal ozama, to which the reader is referred. 

The symptoms consist of a sensation of dryness in the throat, 
which is much more disagreeable than the presence -of an hyper- 
secretion. When crusts form, decomposition takes place, imparting 
a foul odor to the breath. The efforts of the patient at dislodgment 
of these secretions cause gagging and sometimes vomiting, and for this 
reason they produce gastric disturbances. 

The points of diagnosis are identical with those given for ozsena 
under the heading of "Atrophic Nasal Catarrh." 

The prognosis is unfavorable. This is a persistent, chronic dis- 
ease, which is not easily amenable to treatment. However, much re- 
lief may be afforded until such time as the processes of nutrition can 
be so improved as to give permanent relief. 

Treatment. — Hydrozone and antiseptic detergent solutions — such 
as Dobell's and Seiler^s — must be used abundantly to dissolve and dis- 
lodge the crusts. "When no crusts are present, but there is merely a 
pale, dry, shining, mucous membrane, remedies that stimulate the 



322 TUMORS OF THE XASO-PHARYXX. 

muciparous follicles to secretion must be used. These consist of the 
eucalyptol, iodine, and cubeb sprays already mentioned. Further 
treatment for this affection is the same as that laid down for nasal 
ozaena. 

Fibrous Polypi of the Xaso-pharyxx. 

Fibrous polypi in this locality are of infrequent occurrence (Plates 
III and V). They are not found above the twenty-fifth year and occur 
more frequently in males than in females. They cause obstruction to 
nasal respiration, dyspnoea, epistaxis, and facial disfigurement. 

Pathology. — These tumors occur singly and are attached by a 
broad pedicle to the roof of the pharynx. They are dense, smooth, 
and of a dark-reel color. The blood-vessels of the interior are smaller 
than those of the mucous membrane covering them. Bleeding takes 
place easily; so that palpation with the probe causes a sanious dis- 
charge. These polypi may develop to such an extent as to invade the 
throat even to a level with the epiglottis. 

Etiology. — Their cause remains in obscurity. 

Symptomatology. — The most prominent symptoms are difficult 
breathing in consequence of the nasal obstruction, nose-bleeding, 
stupidity, a nasal intonation of the voice, aud difficulty in articula- 
tion of speech. Pressure upon the orifices of the Eustachian tubes 
may cause obstruction to the ventilation of the middle ears, Eusta- 
chian salpingitis, and consequent deafness. When these- growths 
assume large proportions they produce sufficient pressure upon the 
surrounding structures to broaden the base of the nose and increase 
the width between the eyes, giving the appearance suggestive of the 
"frog-face" (Fig. 185), Pressure may be sufficient to cause separation 
of the nasal bones and absorption of the facial and cranial bones, pro- 
ducing intracranial complications. There is generally a copious 
muco-purulent discharge and difficult deglutition. 

Diagnosis. — These tumors are differentiated from mucous polypi 
by their hardness, frequent bleeding, and their occurrence only under 
the twenty-fifth year. They are distinguished from adenoid vegeta- 
tions in the vault of the pharynx by the soft, spongy, lobulated ap- 
pearance of ihe latter and their occurrence only in the very young. 
The appearance of the two in the rhinoscopic mirror and the sensa- 
tions imparted to the finger introduced into the naso-pharyngeal space 
render a differential diagnosis not difficult. 

Prognosis. — Fibrous polypi pursue a steady growth until, in 



TUMORS OF THE XASO-PHABYXX. 32 3 

from three to five years, they prove fatal. If their development can 
be repressed by local treatment until the patient arrives at the age of 
25 years, the prospects of recovery are improved. 

Treatment. — These growths should be removed with the galvano- 
cautery snare, electrolysis, ecraseur, powerful cutting forceps, or a 
curette. Before the operation for removal is commenced the body of 
the polypus should be secured by a strong thread so as to prevent its 
dropping into the throat and producing suffocation. After removal, 
the attachment of the pedicle should be thoroughly cauterized. 

Fibbomucous Polypi of the Xaso-phabyxx. 

These tumors are of somewhat rare occurrence. They vary in 
size from one to ihree inches (two to eight centimetres). They are 
smooth, oval, and of a dusky-red color and occasion nasal obstruction 
and deafness, but no haemorrhage. One serious inconvenience occa- 
sioned by them is the inability to blow the nose. 

Pathology. — Unlike the fibrous growth, which occurs on the 
under surface of the basilar process, the fibromucous polypi, springing 
from the connective-tissue fibres and mucous elements, naturally par- 
take of their character. They are dissimilar to the fibrous polypi: 
are adenoid in appearance, texture, and history; and they do not tend 
to recur after extirpation. 

Treatment. — Evulsion should be made with strong forceps 
through the mouth, or the cold-wire or galvanocautery snare can be 
used through the nose. After their removal the site of attachment 
should be cauterized. 

aLaligxaxt Toiobs of the Xaso-phaeyxx. 

These tumors are of very rare occurrence. They are attended 
with pain in the throat and back part of the nose, extending to the 
ear; catarrhal symptoms, with increased discharges from the nose 
and throat; difficulty in swallowing; and, as they progress, general 
impaired nutrition. They are likely to be of the sarcomatous type, 
either pear-shaped or lobulated. Their growth is rapid, and there is 
a strong tendency to recurrence after their removal. Only a micro- 
scopic examination will reveal their true nature. They are likely to 
be mistaken for fibrous polypi, but are less dense, softer to the touch, 
and present quite a different history. 

The prognosis is hopeless. 



324 ADENOID VEGETATIONS IX THE VAULT OE THE PHAEYNX. 

Treatment consists in their removal, if possible, with the means 
already detailed for operations upon fibrous polypi. Supportive and 
tonic remedies should constitute a part of the treatment. (See "Can- 
cer of the Pharynx.") 

Adenoid Vegetations in the Vault of the Pharynx. 

Synonyms. — Adenomata; hypertrophy of the pharyngeal, or 
Luschka's, tonsil. 

Pathology. — These growths occur in two varieties. The first con- 
sists of spongy, stalactite projections from the vault of the pharynx; 
the second of smooth, fibrous tumors of irregular shape. They are 




Fig. 184. — Contracted upper jaw; narrow roof of mouth with very 
high arch; encroaching upon the nasal fossse; found in habitual mouth- 
breathers who have adenoid vegetations in the vault of the pharynx; 
hypertrophied turbinals and oral tonsils are often associated with these 
conditions. 



very vascular and contain lymph-cells and a follicular structure re- 
sembling that of the oral tonsils. 

The relation of adenoid growths to deaf-mutism has been made 
the subject of investigation by Frankenberg (American Medico-Sur- 
gical Bulletin, December 10, 1897). He examined 158 inmates of the 
deaf-mute institute in Prague. Including adenoids only that were 
large enough to fill the naso-pharyngeal cavity, there were 59 per cent, 
with these growths. Out of the 94 cases, there were 56 boys and 38 
girls. The particular pathological conditions of the ears in these 



ADENOID VEGETATIONS IN THE VAULT OE THE PHARYNX. 325 

subjects can be found under the heading "Deaf-mutism/' page 195. 
Among 426 cases of adenoids Arslan found 6 deaf-mutes. He cured 
one and relieved another of these, both as to speech and hearing, by 
removing the adenoid growths. 

The superior maxillary bone often presents a contracted appear- 
ance; the roof of the mouth is narrow and is highly arched, convey- 




Fig. 185. — A mouth-breather (17 years old). Adenoid vegetations in 
the vault of the pharynx; hypertrophied oral tonsils; bilateral nasal 
polypi; spreading of nasal bones, producing great breadth of nasal arch; 
protrusion and wide separation of eyeballs (frog-face); suppurative eth- 
moiditis requiring curettement ; and chronic suppuration of both middle 
ears. (Author's case.) 



ing the impression that the conformation of the roof of the mouth 
has resulted from the necessities of constant mouth-breathing, en- 
larging the cavity of the mouth at the expense of the nasal fossae 
(Fig. 184). 



326 TREATMENT OF PHARYNGEAL ADENOIDS. 

Etiology. — This is mostly a disease of childhood and is oftenest 
seen under the tenth year. Heredity is an important factor. Oft- 
times several children in the same family are subject to these growths. 
They are always to be looked for in children with hypertrophic rhinitis 
and enlarged faucial tonsils. 

Symptomatology. — The most striking features in a pronounced 
type of this affection are the parted lips, prominent eyeballs, oblitera- 
tion of the normal lines of expression of the face, and a consequent 
appearance of listlessness and inferiority (Fig. 185). Mouth-breath- 
ing, a noisy respiration, snoring, and a lack of resonance of the voice 
are the typical symptoms. There is a characteristic thickness of 
speech, and nasal intonation. As Chaucer said, "He intunes in his- 
nose." Such children are absent-minded and have the appearance of 
being inattentive, which may be due to mental dullness or impaired 
hearing, or both. There is inability to fix the attention, or aprosexia 
(Eumbold), and defective memory. There is a plentiful, tenacious 
discharge of a grayish or bloody color. Examination with the finger 
causes bleeding. The history is one of recurring colds in the head, 
earache, diminished hearing, noises in the ears, or otorrhoea. There 
may be pressure on the Eustachian tube or an extension of the adenoid 
inflammation through the Eustachian tube to the ear. The growths 
are light pink, turning to red on being irritated. They obstruct 
posterior rhinoscopy, and are often unequally developed on the two 
sides. The symptoms given are of typical cases; in many -they are 
not so well defined. 

Diagnosis. — The symptoms described render this a simple matter. 
The rhinoscope is not easily used in children, and we rely mostly on 
the digital examination, with the finger well protected. 

Prognosis.— The tendency is to absorption during early adoles- 
cence and to disappearance when adult age is reached. 

Treatment. — Notwithstanding the fact that, with the advent of 
adult life, adenoid growths in the vault of the pharynx tend to ab- 
sorption, there are most excellent reasons why it is for the patient's 
interest to be rid of them. Semon has formulated these reasons as 
follow: (1) the ever-threatening danger of ear complications; .(2) 
the greater liability to, and seriousness of, infectious diseases, espe- 
cially scarlet fever and diphtheria; (3) the influence of the obstruction 
on the general health, mental development, and the formation of the 
face, results which may remain even if the glands themselves undergo 
atrophy. 



TEEAT^IEXT OF PHARYNGEAL ADENOIDS. 327 

While it is the practice of some rhinologists to treat adenoids with 
washes, sprays, caustics, the galvanocautery, etc., for periods varying 
from four to fourteen months, I much prefer the one painless opera- 
tion, lasting but five minutes and insuring a radical cure. 

The instruments are sterilized by boiling for five minutes in a 
1-per-cent. solution of bicarbonate of sodium, and placed within easy 
reach. The mouth-gag (Fig. 186) is inserted between the molar teeth 
before the anaesthetic is administered, and is held carefully in place 
by an assistant until the operation is completed; otherwise it slips 
out of place and allows the jaws to close, after which they are sep- 
arated with much difficulty. 

The preferable anaesthetic for this operation is ethyl-bromide 
(hydrobromic ether; monobromethane). It is dispensed in 1- (fluid) 
ounce tubes. Before administering it the patient should be calmed 




Fig. 186. 

into a tranquil state of mind, for if there is great excitement the drug 
is not so efficacious. The patient is held in a sitting posture on an 
assistant's lap (Fig. 187), with his feet and arms gently, but firmly, 
pinioned. An ounce of the bromide of ethyl is poured into the in- 
haling-cone or mask and given in the same manner as in etherization, 
allowing a minimum of air to enter. Anaesthesia is induced in about 
one minute and lasts about five minutes. Probably not more than 
half an ounce of the anaesthetic is taken, but the remainder will not 
keep for subsequent use on another day and must be thrown away. 
Fessler gives excellent, practical suggestions regarding the use of 
ethyl-bromide: The preparation must be pure and fresh. The con- 
tents of a bottle must be used up the same day that the bottle is 
opened, or thrown away. Preparations that have been exposed to 
bright light or to air should not be used. For this reason, also, the 
cloths or flannel masks which have once been employed in producing 



328 BROMIDE-OF-ETHYL ANAESTHESIA. 

the narcosis should not he used again hefore having heen thoroughly 
cleansed and aired. 

A good device for administering the anaesthetic can he improvised 
by wrapping a thick towel into the form of a cone and tying a strong- 
cord about its apex to render it the more air-tight, or it can be folded 
into a box shape and pinned with safety pins. Into this inhaler 
should be placed sufficient clean cotton to absorb the fluid. When 




Fig. 187. — Position of child for adenoid operation, or intubation; 
mouth-gag introduced. 

an Esmarch^s mask is used for narcosis with bromide of ethyl the 
flannel should be double the usual thickness, and folded in two layers. 
As soon as the patient is quieted by the means usually employed 
by anaesthetizers and hypnotizers he is directed to draw a long, deep 
breath, to breathe quietly; then the inhaler, into which the anaesthetic 
has just been poured, is held closely over his nose and mouth. A 
slight extension of the extremities will be noticed to follow after a 



OPERATION FOR PHARYNGEAL ADENOIDS. 329 

few inspirations, and the breathing usually continues deep and quiet. 
Complete anaesthesia is attained as soon as this extension begins to 
disappear, and at this instant is the time to operate rapidly, for sensi- 
bility returns again in a few minutes. We may prolong the narcosis 
for a few minutes, only, by adding another ounce (30 grammes) of 
the bromide of ethyl to the inhaler. The patient quickly recovers 
consciousness, and after lying down for a few minutes he is ready to 
be taken home. 

The instant anaesthesia is complete Gottstein's large or small ring- 
curette (Fig. 188) is inserted behind the velum palati and upward near 
the vomer to engage the central, highest mass first. Then the cutting- 
surface is passed backward and downward in contact with the poste- 
rior pharyngeal wall as far as the growths extend. The same move- 
ment is executed on either side wherever there are growths, sweeping 
them all out by three or four passes of the curette. Finally the finger 
is inserted to discover if any remain. If so, they may be detached 




Fig. 188. — Gottstein's ring-curette. 

with the finger-nail or the curette. J. E. Schadle operates by means 
of the finger nail trimmed to a point and hardened by immersion for 
a few minutes in alcohol. (The Laryngoscope, July, 1896.) 

As soon as all the adenoid tissue is extirpated, the gag is re- 
moved and the patient's body is inclined quickly forward, with the 
face downward. The surgeon loudly commands the patient to "spit 
it out!" Hence the blood escapes through the nose and mouth and 
the patient at once begins efforts at expulsion, and the blood is thereby 
prevented from entering the larynx or the stomach. 

If the faucial tonsils are hypertrophied, they are removed before 
the adenoids. This order of operating presents two advantages: the 
space through which we operate is amplified and there is no bleeding 
from above to obscure the tonsillotomy. The operator must waste no 
time, but, if he act promptly and rapidly, there is sufficient time for 
all this procedure under the anaesthesia. 

Haemorrhage lasts but a few minutes and generally ceases by the 
time full consciousness is restored. This method deprives the opera- 



330 HEMORRHAGE FOLLOWING- ADENOID OPERATIONS. 

tion of the horrors experienced by children whose adenoids are ex- 
tirpated without anaesthesia; and neither children nor parents, who 
are excluded from the room until the bleeding ceases, retain any re- 
volting memories of the affair or their doctor. Many cases receive 
no after-treatment; but it is better to give a spray of camphor-men- 
thol and benzoinol — 3 per cent. — with an atomizer (Fig. 129) for 
home use four times a day for a week or more. 

While instances of severe haemorrhage from this operation are 
reported, I have never witnessed any. C. H. Knight reported a case 
of death from haemorrhage following an operation for adenoids in a 
boy 4 years old. Death occurred two days after the operation. (The 
Laryngoscope, April, 1898.) 

James E. Xewcomb had three cases of haemorrhage. One was a 
woman about 18 years old. Another was a girl of 13 years whose 
adenoids were removed under cocaine anaesthesia. Bleeding occurred 
forty-eight hours after the operation. In the third case, which was a 
fatal one, the patient was a boy of 4 years. Four hours after the 
operation haemorrhage set in, and terminated fatally on the morning 
following the operation. The two other cases recovered. On look- 
ing up the subject 16 cases of haemorrhage were found following 
adenectomy, with two deaths. 

Hooper reported a case of death following a digital examination. 

Among 11 cases of these haemorrhages 4 occurred in patients 
under 10 years of age, 5 were between 10 and 20 years oi age, and 
1 was 28 years old. Chloroform was used in 3 cases, and cocaine in 
the same number. Various instruments, as well as the finger-nails, 
were employed. Generally the haemorrhage takes place immediately 
after operating, but it has occurred as late as 24 and 48 hours after- 
ward. 

Delavan has reported a fatal case in a child of 4 years, and 3 
other cases whose ages are not given. In Delavan ? s case there was a 
bleeding diathesis. 

Newcomb mentions "a case of a boy 2 1 / 2 years old who had 
adenoids removed with the finger and forceps, under ether. Haemor- 
rhage occurred 8 hours afterward, and death in 24 hours." 

Van der Poel reports 2 cases of profuse bleeding in his practice. 
The first, a girl of 8 years, was a case of haemophilia. She had suf- 
fered one year before from an alarming haemorrhage following the 
extraction of a tooth. The second was a boy of 14 years who was 
operated on without anaesthesia, and who had a mitral regurgitant 



ADEXOID OPERATION UNDER BROMIDE-OF-ETHTL NARCOSIS. 331 

murmur resulting from rheumatic endocarditis. Both cases recov- 
ered. 

In my experience with the operation none but satisfactory re- 
sults have obtained. One needs to take care not to wound the orifices 
of the Eustachian tubes or to drag a mass of the adenoid tissue down 
into the throat and leave it hanging there by the pharyngeal mem- 
brane intact. I have observed this condition after what must have 
been a hasty and incomplete operation. The finger should not be 
inserted into the pharyngeal vault while the curette is in action; but 
one should not fail to examine immediately after curetting to ascer- 
tain if the adventitious tissue has been completely removed. We have 
never observed any bad effects from ethyl-bromide. It is as safe as 
ether and far preferable for such short operations. 

The operation is not formidable if skillfully performed. It 
should be a thorough curettement, and the cavity is not difficult of 
access, providing that the mouth is kept properly gagged. In more 
than 700 operations by my assistants and myself with bromide-of- 
ethyl anaesthesia no accident or haemorrhage of importance has oc- 
curred. 

Referring to the operation under this anaesthetic, T. Melville 
Hardie says: — 

"The advantages of the drug are: — 

"1. The laryngeal reflex very probably persists, and any blood or 
tissue entering the larynx is promptly expelled. 

"2. The sitting posture of the patient, possible in the exhibition 
of this anaesthetic, is the most convenient one for operating upon 
tonsils and adenoid growths, and makes easy the passage of blood 
from the nose and mouth; little of it is, as a rule, swallowed. 

"3. Xausea and vomiting are rare, and the patient generally ex- 
periences but little discomfort after the operation. 

"The disadvantages of the anaesthetic are: — 

"1. It is not perfectly safe, four or five deaths having been re- 
ported. 

"2. The time of anaesthesia is not always long enough to permit 
of thorough operation. In my experience this is not usual, but it 
cannot, on the other hand, be called very infrequent. 

"3. The anaesthetic is not always well taken." 

TTitzel, who reports 465 anaesthesias, and who believes it to be 
the least dangerous anaesthetic, tabulates the following unpleasant 
effects occurring: in 28 cases: — 



332 ADENOID OPERATION UNDER BROMIDE-OF-ETHYL NARCOSIS. 

"(a) Great excitation in 9 cases, in 4 with much sweating. 

"(d) Cyanosis in 2 students somewhat the worse for liquor. 

"(c) Asphyxia, but rarely with his method: first a few drops, 
then the whole quantity of the anaesthetic. 

"(d) Malaise, lassitude, vomiting. 

"(e) Urination in 3 cases. 

"(f) Great sexual excitement. 

"(g) In 2 cases he could not produce anaesthesia with 1 and 2 
ounces." 

Conclusions. 

1. Adenoid vegetations should be removed under general anaes- 
thesia in the great majority of young children. 

2. The cold-wire snare and cocaine anaesthesia are satisfactory 
in older children and in adults, but cocaine should not be used in 
young children. 

3. Nitrous-oxide anaesthesia is frequently of too-brief duration 
for the proper performance of this operation. 

4. Ethyl-bromide, apart from the question of its safeness, which 
is still undecided, is a desirable anaesthetic in many cases. 

5. Ethyl-bromide is not well taken, as a rule, by very nervous or 
frightened children. 

6. Ether should be substituted for bromide of ethyl when the op- 
eration is likely to be a lengthy one. 

7. The Gottstein curette is, all things considered, the most satis- 
factory single instrument, and particularly in bromide-of-ethyl opera- 
tions. 



PART III 



Diseases of the Pharynx. 



(333) 



PLATE V. 



PLATE V. 



Figure 1. — The anterior nares are dilated by the nasal speculum, exposing the 
inferior turbinated bodies greatly hypertrophied; the head is inclined backward. 

Figure 2. — Hypertrophy of the left inferior turbinated body; removal by 
means of the snare and transfixion-pin under cocaine or eucaine anaesthesia. 

Figure 3. — Posterior rhinoscopic image, normal appearance. 



1. Nasal septum, or vomer. 

2. Superior turbinated body. 

3. Superior meatus. 

4. Middle turbinated body. 

5. Orifice of the Eustachian tube. 



6. Fossa of Rosenmuller. 

7. Inferior turbinated body. 

8. Velum palati and uvuia. 

9. Nasal passages between the septum 

and turbinated bodies. 



Figure 4.— Posterior rhinoscopic image showing 
left inferior turbinated body. 



a posterior hypertrophy of the 



Figure 5. — Posterior rhinoscopic appearance of a case of hypertrophic rhinitis 



showing: — 

1. Superior turbinated body. 

2. Middle turbinated body. 

3. Hypertrophy and great thickening 

of the septum. 

4. Orifice of the Eustachian tube. 



Hypertrophies of the posterior ex- 
tremities of the right middle tur- 
binated body and of the left in- 
ferior turbinal. 



Figure 6. — Pharyngoscopy. 

1. Soft palate. 

2. Uvula. 

3. Anterior pillar of the fauces. 

4. Posterior pillar of the fauces. 



5. Oral tonsil. 

6. Posterior wall of the pharynx. 

7. Retropharyngeal abscess. 



Figure 7. — Pharyngoscopy, 
pharynx. 



revealing a fibromucous polypus of the naso- 



Figure 8. — Laryngoscopy, showing the image of the larynx in the laryngo- 
scopy mirror. The vocal cords are widely separated as seen during a deep inspiration. 
Below the white vocal cords four rings of the trachea are visible. The handle of 
the mirror and the towel on the tongue are cut off. 

Figure 9. — The larynx during forcible inspiration. 



1. Inferior surface of the epiglottis. 

2. Anterior commissure of the vocal 

cords. 

3. Cushion of the epiglottis. 

4. Superior glosso-epiglottic fold. 

5. Lateral glosso-epiglottic fold. 

6. Cricoid cartilage. 

7. Ventricular band. 

8. Ventricle of Morgagni. 

9. Trachea. 



10. Left bronchus. 

11. Literary tenoid fold. 

12. Right bronchus. 

13. Cartilage of Santorini. 

14. Cartilage of Wrisberg. 

15. Ary epiglottic fold. 

16. Hyoid fossa. 

17. Right vocal cord. 

18. Pharyngo-epiglottic fold. 

19. Superior surface of the epiglottis. 



PLATE V. 




8 IftFETODGE CO UTH FHTL' 



CHAPTER XXVIII. 
DISEASES OF THE PHARYNX. 

Acute Pharyxgitls, or Simple Soke Throat. 

Pathology. — Acute sore throat may be characterized by a simple 
hyperemia or an active inflammation with round-cell infiltration of 
the mucous membrane of the pharynx and serous effusion in the sub- 
mucous tissues. The secretions contain epithelial cells, pus-corpus- 
cles, and micrococci. 

Etiology. — There is quite a wide divergence of opinion respect- 
ing the causes of acute catarrhal inflammation of the throat. There 
are excellent students who deny the classic theories of taking, or catch- 
ing, cold. Thorner and Fick combat the idea. But what shall we 
say of the common experiences of life among laymen and doctors 
alike? "When individuals possessed of unusual intelligence and pow- 
ers of observation note that certain phenomena invariably follow given 
causes, that exposure of certain skin-surfaces, like the back of the 
neck, to cold draughts of air, is regularly and repeatedly followed 
closely by symptoms of irritation or inflammation of the nasal or 
pharyngeal mucous membrane, not a few times only, but scores and 
hundreds of times in a long experience, shall we say that human testi- 
mony is not to be accepted, that the powers of observation are at fault, 
the reason clouded, and experience a delusion? Shall testimony of 
such a positive nature as would receive credence, and upon which a 
just verdict would be rendered in law, be not accredited equal weight 
in medicine? The logic of consecutive circumstances and events is 
no less forceful here than in other departments of physics. 

In the case of certain subjects the exposure of the back of the 
neck for a short time to cold winds is just as certain to be followed 
by an hyperemia or an actual inflammation of the nasal or pharyn- 
geal mucous membrane as the inhalation of the fumes of a lighted 
match by a person subject to attacks of hay fever will precipitate a 
paroxysm of that disease. Chilling the skin of the chest by ex- 
posure to cold winds causes a reflex paresis of the blood-vessels of 
the bronchi or lungs, resulting in hyperemia and congestion, or in- 
flammation, of the lining mucous membrane. The same condition of 

(335) 



336 ACUTE PHAKYNGITIS. 

the corresponding membrane of the nose or throat is caused in cer- 
tain sensitive or predisposed persons by the chilling of the feet or 
back of the head or neck, but not by the impression of cold on the 
nose or throat directly. These causes and effects follow each other in 
such quick and logical succession, and are the subjects of such uni- 
versal observation and experience, that one cannot ignore or resist 
their force. 

The theory that these diseases are the result of bacterial infec- 
tion may be, in some part, true, for such micro-organisms may easily 
enough act as exciting causes which cannot be resisted by a membrane 
already weakened by paresis of its vessels caused by the impression of 
cold; but cold is by no means held to be the only predisposing or 
exciting cause of acute catarrhal attacks. Streptococci and other 
germs have been found in the secretions in abundance, but their pre- 
cise relations to the disease, cause or product, have not been deter- 
mined. Acute pharyngitis occasionally follows an extensive or deep 
cauterization in the nasal cavity. 

This affection is an accompaniment or a sequel of the exanthe- 
mata, improper use of the voice, traumatic or chemical injuries of 
the throat, iodism, etc. Predisposing causes are heredity, impairment 
of the digestive and eliminative functions, and living in overheated 
and ill-ventilated rooms. 

Symptomatology. — The first intimation given of an attack of 
acute pharyngitis is a sense of discomfort in the region of the throat 
and more or less stiffness of the muscles concerned in deglutition, or 
actual pain. The temperature rises in severe attacks, especially in 
children, several degrees, even as high as 103°. or 105° F. In mild 
attacks there is no fever. The naso-pharynx is frequently involved 
and the symptoms are proportionately extended. There are likely to 
be headache and symptoms referable to the ear, such as a feeling of 
stuffiness, dullness of hearing, and ringing in the ears. Of course, 
these symptoms are attributable to an extension of the inflammation 
to the Eustachian orifices or tubes. It is not uncommon to see the 
middle ear involved to the extent of acute otitis and suppuration, with 
perforation of the membrana tympani. The act of swallowing causes 
pain, to avoid which the head and neck are made to perform certain 
movements characteristic of painful deglutition. The voice sounds 
muffled and obstructed and its use is avoided on account of the dis- 
comfort produced. During the act of swallowing the food is prone to 
enter the post-nasal space and occasion much discomfort. 



TREAT^IEXT OF ACUTE PHARYXGITIS. 337 

After the dry stage of inflammation has passed, the throat he- 
comes bathed in a sticky mucus. This happens about the second day, 
and soon after this pns-eorpuscles begin to make their appearance. 
The efforts to clear the throat of these rapidly-accumulating dis- 
charges cause so much acute suffering that they are often swallowed. 
when nausea and vomiting are likely to follow. The breath becomes 
foul and the tongue thickly coated, indented, and flabby in severe 
attacks. 

Early inspection shows a bright-red color of the membrane cov- 
ering the fauces and pharynx. At first this is simply hyperamiic, but 
as exudation of serum takes place there appears a swollen, cedematons 
condition, especially marked in the loose tissue of the soft palate and 
uvula. The velum is thickened and its movements restricted and 
painful. The uvula is swelled to much more than its normal size: 
it is elongated and feels like a foreign body in the throat, exciting 
frequent attempts to swallow (Plate IY, Fig. 8). 

The duration of this disease varies from two or three days to a 
week or longer. The high temperature of the initial stage drops 
in a day or two and remains nearly normal. It generally develops 
on examination that the patient has been subject to similar attacks, 
with a suggestiveness of periodicity. They are expected in the fall, 
winter, or spring, which points to the probability that there has been 
a predisopsing chronic inflammation that requires treatment to avert 
future attacks. 

Diagnosis. — Simple sore throat cannot always be distinguished 
from the sore throats of measles and scarlet fever until the eruption 
appears, or from tonsillitis until the glands swell. In rheumatic sore 
throat there is not likely to be so marked an cedematous condition of 
the tissues, but more pain, referable to the cervical muscles. 

Prognosis. — The disease lasts only about a week and is not dan- 
gerous unless it extends to the larynx. 

Treatment. — If seen during the first stage of the attack it can 
be averted or greatly ameliorated by the administration of atropia 
combined with morphia in the proportion of 1 / 400 grain of atropia 
to V 8 grain of morphia. Even in the second stage of inflammation, 
when serum and mucus are pouring forth in abundance, the siccative 
effect of these remedies lessens the secretion and the consequent 
painful efforts to swallow it, while their anodyne properties reduce 
the suffering to a minimum. The atropia antagonizes the nauseating, 
depressing, and constipating effects of the morphia. I have often 



338 TREATMENT OF ACUTE PHARYNGITIS. 

averted these attacks in patients who had been subject to sieges of this 
disease with such distressing regularity that their experience was not 
to be ignored. Instead of suffering for a week or more, the symp- 
toms would either disappear quietly in a few hours or coyer a period 
of only a clay or two, and with but little inconvenience. 

The use of quinine, which is so common among the laity as well 
as among physicians, leads to serious results in numerous instances. 
Some families buy quinine by the ounce and keep it in the medicine 
closet ready for daily doses for the slightest ills. Some of the most 
hopeless cases of deafness I have ever met are those occasioned by 
the use of quinine. It is less effective and more harmful than other 
remedies. At the onset of an attack the patient had better go to bed, 
if the symptoms are severe, and take the tablets mentioned contain- 
ing the atropia and morphia, or the coryza tablets, containing, each, 
caffeine, 1 / 6 grain; morphia, 1 / 12 grain; and atropia, 1 / 600 grain. 
There is seldom any necessity for repeating these more than two or 
six times during the first two days, when the symptoms will often 
have disappeared. It frequently happens that one or two doses are 
sufficient. The effects of one dose last about four or six hours, when 
the patient is directed to take another, providing the symptoms begin 
to revive. He is never allowed to know the nature or the name of 
this remedy for fear of establishing a drug habit. 

The bowels should be opened with a saline draught or a laxative 
pill. A half drachm or more of sodium phosphate is effective. 

The old-fashioned sweats were quite effective, but after leaving 
the bed the skin is like a sensitive plant and every breath of cool air 
has a chilling effect, so that patients are left more liable to take cold 
after the sweat. Moreover, the excessive flow of perspiration is weak- 
ening. The air of the room should be kept moist during the dry stage 
of the first day or two, and steam-inhalations are grateful. These are 
best produced by utilizing some vessel having a nozzle (Fig. 140), 
that may be found at hand in every house, like the tea-pots, into 
which a pint of very hot water is poured. Tincture of benzoin, cam- 
phor, 10 drops of pure camphor-menthol, or a few crystals of menthol, 
are added to the steaming water, a thick napkin is wrapped about the 
nozzle to protect the lips which are to embrace the tip, and this 
medicated steam is inhaled into the throat. It must not be too 
strongly impregnated with the medicaments so as to produce an irri- 
tating effect. 

When both the nose and throat are suffering from an attack of 



TREATMENT OF ACUTE PHARYNGITIS. 339 

acute inflammation, we have found that menthol afforded relief, espe- 
cially during the dry stage, by employing it as follows: a few of the 
crystals are placed in a teaspoon or saucer and heated over a lamp or 
stove until the crystals melt and produce fumes that penetrate every 
part of the rooim Just enough is used to medicate the atmosphere 
to the point of comfortable inhalation. The patient closes or covers 
his eyes to prevent any smarting of the conjunctivae, and is instructed 
to inhale through both his nose and mouth, if nasal respiration is 
possible. This causes a free flow of mucous secretion that bathes and 
moistens the inflamed membrane and greatly relieves the sense of 
burning heat and dryness. 

In order to obtain a continuous effect of ammonium chloride 
on the blood-vessels, and the soothing effect of Tolu and licorice, I 
have prescribed with satisfaction a tablet consisting of the following 
ingredients, or their equivalents: — 

R. Ammonii chloridi, gr. j. 

Tincturse opii camphoratae, 

Syrupi seillse compositi, 

Syrupi Tolutani, . . . . .of each, min. v. 

Extracti glycyrrhizge, . . . . . gr. iij. — M. 

This tablet is dissolved slowly in the mouth, and the resulting 
medicated saliva is kept in contact as much as possible with the in- 
flamed membrane. During the dry stage pilocarpine can be used, if 
it is desired to produce diaphoresis, 1 / 10 or 1 / 6 grain two or three 
times during the day, or enough to produce considerable perspiration. 
Gargles are not very efficient, since they reach only the anterior sur- 
face of the fauces and generally produce much discomfort. Potassium 
chlorate has been a very popular remedy for a long time, but I have 
never been able to observe any beneficial effect from it, except that 
of a detergent in the form of a wash. The bromide of potash pro- 
duces more of a sensation of relief than the chlorate in solution, and 
if swallowed in 10- or 20-grain doses produces a sedative effect. 

The glycerite of tannin causes an exudation of serum and relieves 
the distended blood-vessels, besides contracting the vessels and thus 
modifying the intensity of the inflammation by a double effect; but 
the objection to its use is the necessarily disagreeable method of ap- 
plying it to the throat with a camel's hair pencil or cotton-applicator. 
It cannot be sprayed with an atomizer without heating it to an un- 
comfortable temperature. After using it in my private and dispensary 



340 TREATMENT OF ACUTE PHARYNGITIS. 

practice for many years I must say that it is an effective remedy if 
thoroughly and gently applied, notwithstanding the recently expressed 
disapproval of this remedy by so eminent an authority as Lennox 
Browne. By applying it several times a day the inflammation is sub- 
dued and the attack materially shortened. The author has used 
guaiacol in these cases, but has found different purchases to vary 
considerably in strength. Some specimens cause but little burning 
and smarting when applied pure, while others are very violent in 
their action and need to be diluted one-half. Patients feel relieved 
after the applications, particularly in case of high temperature. In 
some instances in which we used the pure guaiacol the membrane 
looked immediately after the application as if an escharotic had been 
used. It was covered with a light-gray pellicle, and on the following 
morning the mucous membrane of this area was broken down and 
ulcerated. There is the same objection to this that can be urged 
against any remedy that must be applied with a swab or probang. 

Cocaine for this disease is condemned. The effect is transitory, 
unless one takes into account the possible after-effects of a contracted 
drug habit. Thorner has experienced excellent results from salol in 
10- or 15-grain doses four to six times a day. It relieves the pain 
in both pharyngitis and tonsillitis. The writer has experienced similar 
results with this remedy and with salophen. The application of ice 
to the throat externally, which can be accomplished with an ice-bag 
(Fig. 83) and by sucking pieces of ice, if they can be relied upon as 
being free from disease germs, may modify and abbreviate the in- 
flammation. Antipyrin, acetanilid, phenacetin, salophen, and aconite 
are useful during the fever and painful stage. After a muco-puru- 
lent discharge has formed, the antiseptic sprays, followed by the sooth- 
ing, oleaginous inhalents of salol, etc., are beneficial in cleansing, 
disinfecting, and protecting the inflamed surfaces. 

The diet must consist of very nourishing fluids, like the animal 
broths, beef-tea, barley- and rice- water, milk, etc. The body should 
be clothed according to the principles laid down in treating of acute 
rhinitis. One should always dress as warmly as comports with com- 
fort. 

The strong tendency of this disease to extend to the Eustachian 
tubes and middle ears makes prompt and efficient treatment impera- 
tive. The most effective measures for preventing or managing these 
complications are dealt with in the divisions on "Eustachian Tubal 
Catarrh" and "Acute Inflammation of the Middle Ear." 



simple chronic pharyngitis. 341 

Simple Chronic Pharyngitis. 

Synonyms. — Chronic sore throat; chronic catarrh of the throat. 

Pathology. — The condition here is essentially a repetition of the 
process that eventuates in simple chronic rhinitis. Frequently-re- 
curring attacks of congestion and inflammation cause a loss of tonus 
of the blood-vessels, which remain permanently dilated. Varicose 
veins stand out prominently in their tortuous courses, and the mem- 
brane remains thickened. The infiltrated tissues (Plate IV) are de- 
prived, of the power of returning to their normal condition through 
the process of absorption because of the interruption to this process 
occasioned by repeated attacks. 

Etiology. — Generally, simple chronic pharyngitis is the sequel 
of acute attacks, but it may result from the abusive use of alcoholic 
beverages, excessive smoking, indigestion, and torpidity of the liver. 
Persons exposed to a smoky, dusty atmosphere or irritating gases are 
especially liable to this form of catarrh. A diseased condition of 
the nasal membrane predisposes to this affection. 

Symptomatology. — A sensation of stiffness or a parched feeling 
is experienced in the throat, which is only temporarily relieved by 
drinking. The voice is often lowered in pitch and becomes easily 
fatigued. Viscid masses of mucus are sometimes seen clinging to 
the posterior pharyngeal wall, and efforts to remove them result in 
explosive, scraping expulsions of the air that add to the existing 
trouble and set up irritation of the uvula and velum palati. These 
parts are thus forced into participation in the throat trouble and 
often are of a deep-red color, swollen, and the uvula is elongated. 
The resulting contact of the uvula with the tongue aggravates the 
condition already present by provoking a cough and frequent swallow- 
ing occasioned by a feeling as if a foreign body were in the throat. 

Diagnosis. — The conditions already described render the diag- 
nosis a simple matter. It is not likely to be confounded with any 
other disease. 

Prognosis. — This affection is annoying, but not dangerous to life, 
and the prospect of relief is good if the patient is willing to submit 
to continuous treatment for a considerable time. 

Treatment. — After complete cleansing of the pharynx by the 
antiseptic solutions given in Chapter XVIII, Sajous prefers silver- 
nitrate solution, 40 grains to the ounce. It reduces the calibre of the 
blood-vessels and promotes absorption. If silver is used, the strong- 
is preferable to the weak solution. This is applied daily with cotton 



342 ACUTE KHEUMATIC PHARYNGITIS. 

on a holder, with care not to let it drip or press out into the larynx. 
The author has found that patients experience great relief by using 
at home — every morning and night at first, and later, when improve- 
ment is marked, only at bed-time — a 3-per-cent. solution of camphor- 
menthol in benzoinol or lavolin. I have prescribed this for hundreds 
of patients, and they often say, many months afterward, that their im- 
provement was so great and gratifying that they have had the pre- 
scription repeatedly filled, and have obtained the remedy for their 
friends. This is used with a small hand-atomizer (Fig. 129). 

For office-treatment, after the cleansing throat-douche in coarse 
spray with sufficient air-pressure to dislodge and expel all the secre- 
tions that may stick to the membrane, we use, for a protective and 
emollient, benzoinol; for antiseptic and stimulant purposes eucalyptus 
in lavolin, 4 per cent., and pine-needle oil in the same proportions; 
and, if the membrane become too dry from insufficient secretion of 
mucus, 90 parts of oil of cubebs with 10 parts of pure camphor-men- 
thol. This acts as a decided tonic. 

Pernicious habits must be stopped, and indigestion and torpidity 
of the liver overcome by proper treatment and hygiene on general 
principles. 

Acute Eheumatic Pharyngitis. 

Synonyms. — Eheumatic sore throat; rheumatic angina. 

Pathology. — The pathology of this affection is the same as in 
rheumatism, the discussion of which belongs to the province of gen- 
eral medical works. The uric-acid diathesis is discussed under the 
heading of "Hay Fever" (page 236). 

Etiology.— In persons who are subject to attacks of sore throat 
the acquirement of the rheumatic habit of body is likely to be fol- 
lowed by this type of throat affection. Attacks usually follow ex- 
posure to cold and damp. 

Symptomatology. — Attacks come on suddenly after the im- 
pression of cold, and announce their presence by pain in the throat 
and great difficulty in swallowing. The pain of deglutition is so acute 
that the patient refrains from eating or even quenching his thirst. 
All this time there appears to be an increased secretion and flow of 
saliva, which necessitates frequent spitting or the alternative of 
swallowing. This act keeps the sufferer constantly harassed, for the 
movements of the muscles of deglutition cause exquisite distress, and 
with each act the head and neck are seen to execute certain move- 



TREATMENT OP ACUTE RHEUMATIC PHARYXGITIS. 343 

ments characteristic of attempts to avert the inevitable painfullness 
of the act. While the attack lasts the suffering is greater than is 
usually experienced in simple acute pharyngitis, for the soreness in 
the rheumatic form is not confined to the mucous membrane of the 
pharynx alone, but exists in the muscles concerned in the movements 
of swallowing and even in the superficial muscles of the neck, such 
as the sterno-cleido-mastoid. 

These attacks may not last more than a day or two, when other 
parts, like the muscles of the back or the shoulders, may be attacked. 
On the other hand, there are patients who are not conscious of ever 
having had an attack of rheumatism, at least, an acute attack, but who 
are subject to periodical visitations of the typical throat affection at 
certain seasons of the year, either at the change from winter to spring 
or in the late fall. 

The mucous membrane of the palate and pharyngeal wall ap- 
pears of an intense-red color and has a puffy, swelled look. There is 
sometimes headache, accompanied with fever of a mild grade. After a 
few attacks those who are subject to them readily recognize their 
character. 

Diagnosis. — The distinguishing features are the suddenness and 
severity of the attack, the exquisitely-painful deglutition, the sore- 
ness of the cervical muscles, the brevity and shifting character of the 
disease, and the rheumatic history. 

Prognosis. — This disease is self-limited, so far as its manifesta- 
tions in the throat are concerned, for it passes off in about four days, 
but to return again on exposure. Prompt treatment will avert at- 
tacks. 

Treatment. — Salicylic acid in some form is the most effective 
remedy. The author prefers a freshly-prepared salicylate of sodium, 
and generally prescribes it in the following formula: — 

R Acidi salicylici, 3iij. 

Sodii biearbonatis, 3ij. 

Elixiris gaultherise, §ss. 

Glycerini. . 3iij. 

Aqiue, . . . . . . . q. s. ad §iv. 

Misce. Signa: One teaspoonful, in water, every two or four hours. 

This is given every two hours, at first, until a perceptible im- 
provement is shown or until the physiological effects are manifested: 
ringing in the ears and slight impairment of hearing. Then the doses 
are stopped or diminished or placed sufficiently far apart to avoid 



344 CHRONIC RHEUMATIC SORE THROAT. 

these effects. The latter are similar to those of quinine, and must be 
avoided as far as possible, so as not to produce hyperemia or con- 
gestion of the middle ears or irritation of the auditory nerves. If 
the salicylate is not well borne, if gastric disturbance and head symp- 
toms indicate unusual susceptibility to this drug, salicin can be ad- 
vantageously substituted for it. This is best given in pilular form in 
doses of 5 grains, as detailed for the administration of the salicylate. 
In my opinion these preparations are preferable to the alkalies, 
guaiacum, or salol, although the latter and salophen, as well, produce 
excellent effects. 

For the fever and pain antipyrin affords the most decided relief. 
Indeed, this remedy appears to exercise a special influence in quelling 
this disease, and is superior to phenacetin, acetanilid, etc., not only 
in reducing temperature, but in transcending the limited action of 
an antipyretic. Potassium bromide, bromidia, or morphia, combined 
with a proportionate amount of atropia, may be called for to subdue 
the pain. Effervescent citrate of lithia, soda, and potash and alka- 
lithia are indicated to rid the blood of uric acid and to prevent sub- 
sequent attacks. 

As an external application, I have found the following liniment 
efficacious: — 

B Olei tiglii, 3ij. 

Chloroformi, 3ij. 

Aquae ammonii fortioris, . . . . • Bj- 

Olei sesami, Siij- 

Misce. Signa: Apply on cotton. 

This is used by saturating a layer of lint or cotton, which is 
applied to the whole anterior and lateral aspects of the neck and then 
covered with a thick layer of cotton. The underclothing should 
always consist of wool. 

Chronic Bheumatic Sore Throat. 

Synonym. — Gouty sore throat. 

Pathology. — This has generally passed under the name of gouty 
sore throat and is due to the same causes that operate to produce 
various rheumatic or gouty manifestations in other organs. There 
is undoubtedly an increased formation and a retention of uric acid 
in the body, and these processes, together with their resulting mor- 
bid phenomena, are discussed at length in the chapter on hay fever 
(page 236). 



TKEATMENT OF CHROXIC BHEUMATIC SOEE THEOAT. 345 

Symptomatology. — This disease differs from acute rheumatic 
sore throat principally in degree. There is not acute suffering ex- 
cept in exacerbations of the disease, when it lapses into the acute form. 
It usually comes on at the same changeable seasons that excite the 
acute attacks, but may be present in greater or less conspicuousness 
throughout the year. In this case it is more troublesome during the 
winter months. 

There is a sense of discomfort, perhaps ill-defined, but annoying. 
in and about the throat, sometimes extending to the larynx or even to 
the trachea. When these lower air-passages are involved, it is often 
in consequence of cold, damp, chilling winds from the Northwest. 
Pressure over the larynx or the hyoid bone reveals tenderness and 
soreness of the parts, suggestive of perichondritis or periostitis. The 
patient is conscious of an indefinite sensation described as a constric- 
tion or an aching, which is increased by considerable use of the voice. 

The laryngeal mucous membrane is not generally involved to 
the extent of producing hoarseness or presenting positive indications 
of the disease on laryngoscopy. 

Diagnosis. — This disease must be differentiated from the simple 
inflammation of the throat and from tuberculosis, syphilis, and can- 
cer. However, the spasmodic, intermittent, and characteristic history 
of this trouble ought to facilitate the forming of an opinion. The 
physical appearances are generally negative as compared with the 
malignant diseases which are distinguished by visible lesions. In the 
latter diseases we find the cachexia or constitutional condition indi- 
cated by the particular infection in each instance. 

Prognosis. — If the rheumatic or gouty habit has not existed too 
long, or is not of too severe a type, the prospect of relief as the result 
of treatment is good. The disease is not dangerous. 

Treatment. — The internal medication consists of that already 
described for the acute form, with the addition of a prolonged use 
of lithium. This remedy should be taken in appreciable doses rather 
than in the so-called lithia-waters extensively advertised in the news- 
papers. These waters often contain so little lithia according to the 
admittedly-correct analyses that one must needs swallow the startling 
draught of six thousand gallons of water to get an ordinary dose of 
lithia. The most convenient preparation is a tablet of effervescent 
citrate of lithia containing 3 grains, made by Wm. E. Warner & 
Company. Two or three of these are dissolved in a large glass of 
water — the more water, the better — and taken once or twice a dav 



3±6 TREATMENT OF CHRONIC RHEUMATIC SORE THROAT. 

for months in succession until the rheumatic or gouty habit is over- 
come. I have known of no serious disturbances following the pro- 
longed use of lithia in this form, although I have given it over very 
protracted periods. A few persons are susceptible and have symptoms 
of strangury if too much is taken. Others do not use a sufficient 
quantity of water and have a slight gastric disturbance. Alkalithia 
and the effervescent citrate of lithia, soda, and potash, of Keasbey 
and Mattison, are also very effective. 

The sufferers from this disease, like most other people, drink too 
little water to dissolve the waste-elements of the body and eliminate 
them. We flush the sewerage system of a city to increase freedom 
from infection; but how much more important it is to flush the 
sewerage of the body and wash out the waste-products of tissue 
metamorphosis and prevent infection of the system by the results 
of decomposition. The success of the water-cures in these diseases 
lies largely in the amount of water passed through the body, taking 
up the debris of the tissues, dissolving out the urate of soda from the 
joints, the liver, and the more alkaline tissues, in which it is stored 
only to enter the blood when it becomes sufficiently alkaline in re- 
action and then to rack the body with pains. 

The clothing should always be sufficient to keep the person as 
warm as comports with comfort, and wool is preferable to silk, for it 
is a more perfect protective against rapid changes of the temperature. 
Cotton or linen must never be worn next the skin. The bowels must 
be kept regular. 

If sensitive spots are detected in the throat or larynx, a 10-per- 
cent, solution of carbolic acid in glycerin can be applied to the painful 
area. The local anaesthetic effect of the carbolic acid affords relief 
without cauterizing- the tissues, bv the use of this combination. 



CHAPTER XXIX. 
DISEASES OF THE PHARYNX. CONTINUED. 

Sore Throat of Measles, Scarlet Fever, axd Small-pox. 

sore throat of measles. 

The mucous membrane of the throat often participates to a 
large degree in the eruption of measles, and, although it generally 
is not severe enough to require special treatment, I have seen it so 
intensely involved as to necessitate as persistent efforts as the diph- 
theric throat. In this class of cases the mortality amounts to 80 per 
cent. 

If the throat is examined ahout the time the fever appears it is 
found to he hyperaernie, and this condition increases to a congestion 
by the third or fourth day of the fever when the eruption is noted. 
In the membranous form an exudation occurs that closely resembles 
the false membrane of diphtheria. If this is removed, an uneven, 
raw-looking, ulcerating surface is found beneath. The inflammation 
and exudation cover the soft palate, uvula, tonsils, and posterior 
pharyngeal wall in severe cases. The swelling of these parts is great, 
the velum palati is paretic, swallowing is torturesome, and the tongue 
and general condition are indicative of a grave disease. The ulcer- 
ative process may extend deeply enough into the tissues to eventuate 
in abscesses. Instances of Eustachian tubal catarrh and middle-ear 
complications are numerous. 

The larynx is often invaded in measles, but generally only to 
the extent of setting up a catarrhal condition such as commonly affects 
the trachea and bronchial tubes; but, if the diphtheric form of 
measles affects the larynx, the outlook is a very discouraging one, for 
four out of five of these cases die. 

Treatment. — The simple catarrhal sore throat requires treatment 
principally to prevent middle-ear involvement. The measures rec- 
ommended for acute pharyngitis are sufficient, but the membranous 
form should be treated with as unremitting thoroughness as diph- 

(347) 



348 SORE THROAT OF SCARLET FEVER. 

theria, the treatment for which is indicated here. (See chapter on 
diphtheria.) 

SORE THROAT OF SCARLET FEVER. 

As in measles, so in scarlatina, the pharyngeal mucous membrane 
is generally concerned, but in the simple form of the disease the 
throat involvement is not serious. In the severe form the membrane 
becomes intensely injected and of a dark-red color. Infiltration of 
the tissues produces swelling that is apparent to the eye on inspection, 
and even the neck may present a swollen appearance. The glandular 
bodies with which this region is so richly supplied — the tonsils and the 
parotid, submaxillary, and lateral cervical glands — may all be in- 
vaded by an intense phlegmonous inflammation with resulting ab- 
scesses. 

The throat may be inflamed even when the eruption of scarlet 
fever is absent. As in measles, the swelling and oedema involve the 
soft palate as well as the pharyngeal walls, and suppuration and ab- 
scesses may occur if the necrotic process extend deeply into the sub- 
mucous tissues. Middle-ear diseases more often result from scarlatina 
than from measles, and the results are far more disastrous than from 
measles. Suppuration of the tympanic cavities with resulting granu- 
lations, polypi, extensive caries, and necrosis, as well as a high degree 
of deafness, are frequently attributable to scarlet fever. 

A malignant type of this disease occurs that takes on the form 
of diphtheria. The throat symptoms do not make their appearance 
until a week or longer or until the exanthem and fever have disap- 
peared. Then the throat is attacked, the submaxillary glands swell, 
the throat is covered with a diphtheric membrane, a foul discharge 
takes place, and the breath acquires a fetid odor. The larynx is some- 
times invaded, producing the croupy form of scarlatina. The glands 
at the angle of the jaw may suppurate, and the resulting abscesses, 
breaking outward, leave scars at this point. 

The diagnosis is aided by the presence of an epidemic, and doubt 
is set at rest by the appearance of the eruption. In the membranous 
form culture-tests for the presence of the Klebs-Loffler bacilli should 
be made to determine whether or not we have to deal with true 
diphtheria, and in the absence of bacteriological facilities the disease, 
as far as the throat is concerned, at least, is to be treated on the 
theory that it is diphtheria. 

The prognosis in scarlet-fever sore throat, if this is a prominent 
feature of the disease, must be guarded, for the throat affection often 



FOLLICULAR PHARYNGITIS. 349 

causes death. In the simple form it is not dangerous; but in the 
severe, or anginose, form about 25 per cent, die, and about 50 per 
cent, of the diphtheric cases prove fatal. 

Treatment. — Aside from general treatment, which is properly 
left to general works on medicine, the throat should receive special 
attention when it gives promise of becoming seriously involved. In 
the first stage of the inflammation cold, in the form of an ice-bag 
(Fig. 83), may modify the intensity of the inflammation and avert 
or retard the tendency to suppuration. The throat-tablets and other 
remedies recommended in the treatment of acute pharyngitis are more 
effective than gargles. In the pseudomembranous form, which may 
prove to be a diphtheric complication, the treatment for diphtheria 
must be followed. Eufus P. Lincoln recommends the application of 
pyoktanin. 

SORE THROAT OF SMALL-POX. 

The pustular eruption of small-pox makes its appearance in the 
throat in many cases, and I have seen it extend forward to the buccal 
cavity. The amount of the throat eruption corresponds to the viru- 
lency of the attack. The swelling and inflammation may become suffi- 
cient to cause pain and difficulty in swallowing. The inflammation 
extends in many instances to the larynx and trachea, and the result- 
ing oedema has caused suffocation and death (Plate VII). 

In mild attacks there is no danger; but invasion of the larynx 
is a grave complication. 

Treatment. — The cleansing and disinfecting sprays followed by 
the protective and emollient and oily preparations given in Chapter 
XVIII are indicated. If the oedema extend to the larynx, scarifi- 
cation must be resorted to in order to prevent suffocation, and indeed 
it may become necessary to intubate or perform tracheotomy. In the 
diphtheric form resort must be had to the treatment described in the 
chapter on diphtheria. 

Follicular Pharyngitis. 

Synonyms. — Folliculous, or granular, pharyngitis; clergyman's 
sore throat. 

Pathology. — There are two forms of follicular pharyngitis, — the 
hypertrophic and the exudative. In the first form the follicles are 
enlarged and stand out prominently upon the membrane, while in 
the second, or exudative, form there is a secretion of a light color, 



350 FOLLICULAR PHARYNGITIS. 

which may become dried and cheesy in consistence and appearance. 
In the hypertrophic condition the morbid changes are epithelial 
rather than follicular, but in the exudative form the follicular tubules 
are distended and their walls thickened, and chalky deposits are some- 
times found within the follicles. 

In the case of public speakers the severe tests to which the vocal 
organs are put increase the demands on the glandular elements to 
furnish an extra amount of the lubricating secretions. This pro- 
tracted exercise results in increased blood-supply and deposit of nu- 
triment, or an excess of growth of the glandular tissues, and this, 
together with occlusion of the apertures of the follicles, accounts for 
their hypertrophic condition. Irritating discharges from the naso- 
pharynx serve to excite inflammation in the orifices of the follicles, 
resulting in their constriction or obliteration. 

Etiology. — It is not a simple matter to account for this disease, 
for it exists in young children who are not exposed to the irritants to 
which the disease is usually attributed: excessive use of the voice, the 
inhalation of dust, gases, smoke, etc. There seems to be an inherent 
tendency to a proliferation of cells in the mucosa. It is especially 
prevalent in those having the strumous diathesis. Old age seems 
quite exempt from this form of throat trouble, but presents the 
atrophic stage of pharyngitis. 

Symptomatology. — In the early stage of this disease the patient 
complains of dryness of the throat or a tickling sensation that occa- 
sions frequent efforts to relieve, and a slight hacking cough. The 
voice assumes a husky quality and tires after speaking or singing a 
short time, and while using the voice transitory lancinating or shoot- 
ing pains occur. 

The dry stage is followed by a mucous secretion which is often 
stained with pus or blood. The discharge is usually thick and tensile, 
and clings to the posterior pharyngeal wall or sticks to the posterior 
surface of the velum. If it is not too abundant it dries into scales or 
crusts. The membrane covering the back wall of the pharynx is 
studded with several spongy, red masses, or is sometimes quite cov- 
ered with them. They are in some instances punctated, appearing 
like little nipples; in others they have broad bases, are flat, and 
become coalesced in patches. Behind and external to the posterior 
faucial pillars their union forms a ridge extending upward and out- 
ward toward the Eustachian orifices. The blood-vessels are engorged 
and the veins are abnormally prominent. 



TREATMENT OF FOLLICULAR PHARYNGITIS. 351 

The tonsils are enlarged in a considerable proportion of these 
cases and the uvula is relaxed and tickles the tongue (Plate IV). 
The membrane intervening between the follicles may be atrophied and 
of a grayish-white color that will convey an impression, at first sight, 
of pus. 

Diagnosis. — Cohen mentions the presence of ulcerated patches 
in this affection, which would render one liable to mistake this for a 
syphilitic throat, but I do not remember to have encountered this 
condition. Eliminating the question of ulcers, which must be very 
rare, there is little likelihood of this being mistaken for syphilis or 
tuberculosis. 

Prognosis. — If let alone follicular pharyngitis may be expected 
to invade the larynx and seriously affect the voice for speaking and 
ruin it for singing, or it extends to the Eustachian tubes and through 
them to the middle ears, resulting in hypertrophic or sclerotic catarrh 
of these important organs. At last the history of this disease brings 
us to the fourth stage of throat catarrh, or atrophic inflammation, 
resembling atrophic rhinitis. 

Treatment. — The physician does not often enjoy the opportunity 
of treating this disease in its early stages, for the symptoms are not 
urgent enough to suggest the need of medical services. As in the 
other inflammatory processes, cleanliness is the first prerequisite. 
The alkaline and antiseptic washes and the oleaginous sprays discussed 
in the chapter on those subjects are useful here. After perfectly 
cleansing the nose and throat, for this is the first step in the treat- 
ment, the follicles, two or three at a sitting, should be reduced by 
the application of chromic acid, London paste, or — better still — the 
galvanocautery. If the acid or paste is used, great caution is neces- 
sary not to let it drop into the larynx or oesophagus or spread upon 
the surrounding membrane. The chromic acid is applied in the 
form of a bead of the crystals fused upon the platinum wire-loop ap- 
plicator (Fig. 71). The London paste is applied in small particles so 
that they will adhere like minute spots of plaster on the surface of 
the follicles. 

The galvanocautery (Fig. 149) is the most satisfactory means of 
eradicating the tumefied follicles. The long electrode is chosen ac- 
cording to its fitness for the particular condition present and applied 
to the apex or centre of the follicle before the current is turned on. 
Then the circuit is closed for an instant until the tumefaction is 
burned so as to destroy it to a point a little below the surface of the 



352 MEMBRANOUS SORE THROAT, NON-DIPHTHERIC. 

adjacent membrane. On the following day the hypertrophied tissue 
is seen to have given place to a gray surface that will be cast off 
as a slough in about a week. By repeating this process a number of 
times all the enlarged follicles can be dispersed. In the meantime 
cleansing, soothing, and protective remedies should be applied in the 
form of sprays,- such as a 3-per-cent. solution of camphor-menthol, 
benzoinated lavolin, and a 4-per-cent. solution of eucalyptol in lavolin. 
These should be used once or twice a clay, preferably at bed-time and 
on rising in the morning. 

General treatment is demanded by a uric-acid diathesis to pre- 
vent rheumatic or gouty attacks in the throat, and, if the digestion is 
faulty or the eliminative functions are impaired, remedies must be 
addressed to these conditions. The local treatment is often aided by 
tonics and alteratives. 

Membranous Sore Throat, Non-diphtheric. 

Synonyms. — Simple membranous sore throat; herpetic pharyn- 
gitis. 

Pathology. — There occurs occasionally a form of sore throat 
characterized by an exudate that covers the pharynx and fauces, and 
extends upward and forward toward the hard palate on its inferior 
surface, resembling the diphtheric membrane. This is the result of 
an herpetic eruption in the throat, the blisters of which rupture and 
cover the membrane with their contents. 

Etiology. — The cause of this affection is not known, but it is 
more prevalent during epidemics of diphtheria than at any other time. 

Symptomatology. — The initiatory symptoms are very like those 
of diphtheria, except that they are of diminished intensity. There 
are chills; fever of 101° or 103° F.; rapid pulse; dirty, indented 
tongue; dry throat, with burning pain; and difficulty of swallowing. 
Blisters are often found coincidently on the lips. 

In the beginning of the attack the membrane of the throat is 
of a deep-red color and is dotted with follicles that are inflamed or 
pustular in character. As these pustules rupture and their contents 
escape over the surrounding surface the appearance of a false mem- 
brane is given to such patches. The seat of each ruptured pustule 
may become an ulcer, and these grouped together present irregular 
areas of ulceration. 

Diagnosis. — Simple membranous sore throat may be confounded 
with diphtheria, but it is not so grave a disease. Although it may 



TREATMENT OF MEMBRANOUS SORE THROAT. 353 

be ushered in by symptoms simulating diphtheria and with a high 
fever, generally all the symptoms are of a milder grade. The simple 
membrane is much thinner, — indeed, one can almost discern the mu- 
cous membrane beyond, — while in diphtheria the false membrane is 
three or four millimetres thick and closely adherent to the surface 
beneath. In the simple disease the membrane is easily detached by 
means of cotton on a carrier, leaving a smooth surface, while detach- 
ment of diphtheric membrane reveals raw, uneven, ulcerating tissues 
exposed to view. Bacteriological examination in diphtheria shows 
the presence of the Klebs-Lorfler bacillus, which is the germ of that 
disease, while the tests of the simple form are negative. The sputa 
and sections of the membrane should be submitted to the culture-tests 
in this or any other disease in which diphtheria is suspected. It 
has become an easy matter in large cities like Chicago, where there 
are laboratories for such purposes and the health department of the 
city government conducts such experiments. 

Prognosis. — This disease in itself is not dangerous, bitt it should 
not be forgotten that true diphtheria sometimes is ingrafted upon it, 
especially during epidemics. 

Treatment. — During the first stage, when the fever is high, 
guaiacol diluted one-half with glycerin and applied with cotton on 
a holder mitigates the symptoms, and is indicated on account of its 
effect in reducing the temperature. It is best not to use it in full 
strength, for it has sometimes appeared to have a destructive effect 
on the mucous membrane, and we have found on the day following its 
application an ulcerated surface corresponding to the area touched 
with the pure guaiacol. Hydrozone should be sprayed into the throat 
every few hours, the intervals depending on the rapidity with which 
the false membrane is formed. But it is not necessary to use it fre- 
quently if it cause much smarting and burning, for the gravity of the 
disease does not warrant it. If considerable pain is produced by the 
H 2 2 , it probably contains too lar^ge a proportion of acid and requires 
dilution. Ingals prefers the following pigment: Morphia? sulphatis, 
gr. iv; acidi carbolici, gr. xxx; glycerini, fgj; to which he adds 30 
grains of tannin when an astringent is required. John Xorth has 
stated to me that potassium permanganate will dissolve the false mem- 
brane. He uses 30 grains to the ounce of water. 

Inhalations and sprays are more easily applied and cause less dis- 
comfort than swabs and probangs. I have seen much relief afforded 
by adding 10 drops of pure camphor-menthol to a pint of hot water 



354 TREATMENT OF MEMBRANOUS SORE THROAT. 

for the patient to inhale through the month. A benzoinol inhaler 
(Fig. 140), an ordinary tea-kettle, small tea-pot, or coffee-pot can be 
pressed into service for. this purpose. The nozzle is wrapped with sev- 
eral thicknesses of cloth, not occluding the opening itself, so as to 
prevent burning the lips, and the end of the nozzle is taken between 
the lips while the steam impregnated with the fumes of the medicine is 
drawn gently into the throat. This has given good results in other 
forms of sore throat. Carbolic acid in glycerin, of 5- or 10-per-cent. 
strength, will deplete the blood-vessels and anaesthetize the mucons 
membrane sufficiently to relieve pain. Sprays of encalyptol, camphor- 
menthol, or salol in 3-per-cent. solutions — after the alkaline antiseptic 
sprays already given in Chapter XVIII — have a refreshing effect. 

The general treatment, diet, and hygienic and prophylactic meas- 
ures appropriate to this disease are the same as those recommended 
in the treatment of coryza and acute pharyngitis. 



CHAPTER XXX. 

DISEASES OF THE PHARYNX,. CONTINUED. 

DlPHTHEEIA. 

Unlike the sore throats of scarlatina, measles, and sniall-pox, 
in which a pharyngeal manifestation is not a necessary element of 
the disease, or in which, if it exist, it is merely incidental to a con- 
stitutional malady, in diphtheria we recognize a veritable throat 
affection with systemic infection. The importance of the disease and 
the advancements recently made in its pathology and treatment war- 
rant an extended presentation of the subject. 

Since the discovery of the microbe which causes diphtheria by 
Klebs, in 1883, the method and nature of the disease have been 
illuminated by the researches of Loffler, Roux, Welch, Prudden, and 
others. 

Pathology. — In true diphtheria there is always present in the 
membranous deposits in the throat a micro-organism that is not found 
in like exudates of other diseases. This microbe is easily differentiated 
from others and can be isolated and propagated in culture-tubes. 
When animals like guinea-pigs and rabbits are inoculated with this 
organism the disease which produced the microbe is reproduced in 
the susceptible animals. Extensive experiments and studies by sci- 
entific observers have conclusively demonstrated that this disease is 
one of local origin, with constitutional phenomena, depending upon 
the absorption of a poison generated by the specific micro-organism. 
The false membrane of diphtheria abounds in these microbes in its 
superficial layers, but they are not found in the stratum next the 
mucous surface, and generally not in the mucous membrane itself. 
The poisonous principle evolved by this microbe is comparable to the 
venom of serpents, and in this connection it is instructive to observe 
that in contrast to this deadly microbe another is found identical with 
it in biological and morphological characteristics, but lacking in the 
power to destroy the lives of susceptible animals. This has been 
termed the false, or pseudodiphtheric, bacillus. Concerning the 
variations in the pathogenic properties and powers of these bacilli, 
Abbott says, in the Medical News for Xovember 17, 1891: "It was 

(355) 



356 



DIPHTHEKIA. 



observed that the genuine, virulent diphtheria bacillus was liable to 
fluctuate in the degree of its pathogenic properties, at times possess- 
ing these to such an extent that, when inoculated into guinea-pigs, 
death resulted in from thirty-six to forty-eight hours, while again the 
period of inoculation was much longer, often reaching five or six 
days, and in not a few cases organisms were obtained from undoubted 
cases of diphtheria that failed to give more than a temporary local 
reaction when inoculated into these animals." 

The micro-organism of diphtheria is named the Klebs-Lofner 
bacillus (Figs. 189 and 190), after the scientists who have brought 




Fig. 189. — Diphtheria bacilli. Culture on agar-agar, twenty-four hours 

old; stained in alkaline methylene-blue ; magnified 

1000 times. (After Krieger.) 



to light the germ that causes untold suffering and a vast waste of 
human life. When this bacillus comes in contact with a mucous 
membrane or with abraded skin an inflammation is excited. The 
conditions then are favorable for the development and propagation 
of bacilli, — warmth and moisture, — and, while the microbes them- 
selves do not enter into the lymph or blood circulation, their poison- 
ous product does. In this manner an infection of the whole system 
takes place, — a toxaemia of specific type. This poison introduced into 
the blood of guinea-pigs and rabbits in minute quantities produces 
death, and its potency is retained for long intervals in a vacuum. 



DIPHTHEE1A. 357 

According to Yersin and others, the bacillus itself is not virulent, but 
the poisonous product of the microbe is the material that causes 
paralysis in sheep and dogs, and death in rabbits. A similar bacillus 
is also found in the mouths of individuals who have never had diph- 
theria and who have not been exposed to it. To all appearances this 
is the true Klebs-Loffler bacillus deprived in some way of its virulency. 
It may have become modified or attenuated, but whether its poison- 
producing powers can become revivified is not known. These facts 
demonstrate that practical]}- two diseases have formerly passed under 



It* <s 




j 



av A '1-n A 











Fig. 190. — Diphtheria bacilli. Culture on blood-serum, prepared as 
Fig. 189; magnified 1000 times. The short form presented in this specimen 
is due to their rapid multiplication. Some of the germs are distinguished 
by a club shape, which is considered characteristic of this species. (After 
Krieger. ) 

the name of diphtheria, just as previously to the present century 
scarlatina and measles were supposed to be identical. 

In true diphtheria the infection and toxaemia condition are pro- 
duced by the Klebs-Lofner bacillus, but in false diphtheria this ba- 
cillus is absent or is changed in character, and in its place are found 
the streptococcus longus, the streptococcus pyogenes (Fig. 191), and 
the staphylococcus. 

False diphtheria is a much milder disease than the true form and 
is far less frequently productive of paralysis. Although these two 
forms of the disease cannot be differentiated except by bacteriological 



358 



DIPHTHERIA. 



methods, Baginsky, Virchow, Henoch, Smith, and others recognize 
the dnal character of the disease. In the trne form the streptococcus 
and staphylococcus are often found associated with the Klebs-Loffler 
bacillus, and even the internal organs are invaded by the cocci, where 
the bacilli of true diphtheria do not penetrate. The cocci have been 
found in the lungs and kidneys as well as in abscesses of the neck. 

The bacillus of true diphtheria is possessed of remarkable vitality 
and may convey the disease after months and even years of latency. 
D'Espine and others found their potency unimpaired in cultures of 
sixteen months. Cases are on record in which infection occurred 




Fig. 191. — Streptococcus pyogenes. Streptococci and leucocytes of human 

pus; stained in gentian- violet ; magnified 1000 times (Pfeiffer 

and C. Fraenkel). (After Krieger.) 



from clothing and other articles after as many as twenty years, and 
these are authenticated by observers of undoubted competency and 
credibility. 

Diphtheria usually attacks persons under the age of 30 years, 
but may occur at any period of life. Its relative frequency in the 
very early years would almost justify the designation of a disease of 
childhood. Out of 1512 cases in one statistical table I find that 1309 
occurred in children under 6 years and only 203 from 6 to 17 years. 
In another table including adults 70 per cent, of the cases were under 
18 years, 20 per cent, were between 18 and 30 years, and only 10 per 



DIPHTHERIA. 359 

cent, were above 30 years. It has been observed very infrequently 
in infants under 6 months old; but at this age the organism appears 
to be nearly immune against this disease. 

The period of incubation varies greatly, there being as wide a 
margin as from one to twenty days. In animals directly inoculated 
the variation is only from half a day to three days. The sooner the 
disease makes its presence known, the more virulent is the type of 
attack. When the onset is slow and sluggish it seems to indicate 
either the modification or attenuation of the infecting germ or the 
strong power of resistance of the system. 

Etiology. — Diphtheria is not a sporadic disease, since it cannot 
arise in a body independently of any extraneous cause. It can re- 
produce, but cannot produce, itself. The disease originates in any 
individual in the following manner: The specific micro-organism 
known as the Klebs-Loffler bacillus gains lodgment upon the mucous 
membrane or denuded skin. There it grows and multiplies, and 
during this development of cultures of the germ a poison is produced 
that is chemically analogous to the venom of serpents, and the analogy 
may be extended to include its virulency.- The resulting pathological 
manifestations are a reproduction of the disease whence the infecting 
germ was derived. An exposure of a susceptible person to the specific 
microbe for only an instant may be sufficient to insure its reception 
upon a favorable soil; and so rapid is the process of propagation and 
toxaemia that a few hours — or days, at most — witness the develop- 
ment of this plague of nations. 

Abbott, in the Medical News for November 17, 1894, speaking 
of the Klebs-Loffler bacillus, pithily puts his views in these words: 
"If this agent is present, diphtheria exists; if it is absent, then the 
local conditions and constitutional manifestations must be attributed 
to some other cause, and the disease is not diphtheria." The vitality 
of the bacillus, extending over many months or years, seems to insure 
the enduring nature of this decimator of communities. This is not 
an exaggerated characterization, for I have been in an epidemic that 
has literally annihilated family after family of children until the 
population was dazed by the devastation. 

Contact of persons with those who are, or have been, suffering 
with diphtheria is not necessary to constitute exposure. Merely the 
inhalation of a patient's breath, or being in the same room, or being 
in the presence of one who has been in such a situation and who may 
carry the infection in his clothing, or handling a book between the 



360 DIPHTHERIA. 

leaves of which the germs may have found their way, may result in 
communicating the disease. The bearing these facts have on the use 
of library books and the antiquated form of kissing the bible in courts 
and societies is too apparent to need expatiation. 

These germs naturally harbor where millers, moths, and molds 
thrive most. Dark, damp, badly-ventilated, and filthy places seem 
to be their appropriate habitat. It is commonly believed that the 
sewers of a city are the conveyors and distributors of this poison. 
Unless the sewer-traps are perfect and the sewers abundantly flushed, 
it is evident how the houses along the line of a sewer-system may be- 
come, one after another, the recipients of a poison entering farther 
up the stream. These microscopical germs are disseminated by vapors 
and winds and they penetrate our homes with escaping sewer-gas. 
This view is substantiated by the fact that the death-rate from diph- 
theria is twice as great in cities as in rural districts, according to 
our vital statistics. 

The subtile nature of this microbe and its fondness for its vic- 
tims and its vitality and power of propagation are suggestive of the 
multitudinous ways of infection and of the necessity of unceasing 
vigilance to escape it. One never knows when a child in school or in 
a public conveyance may not be sitting beside a diphtheric individual, 
and it seems as though no argument were needed to show the abso- 
lutely dangerous character of the universal habit of kissing children, 
who, in fact, are much more susceptible to this deadly disease than 
the adults who wantonly expose them. 

Surgeons have contracted diphtheria and many have lost their 
lives by means of a particle of the membrane or discharges from a pa- 
tient's throat coughed into their eyes or upon their lips or by receiving 
it upon an abraded surface of the skin. When making examinations 
of the throat they have forgotten either to wear protecting glasses 
over their eyes or to keep at one side of the line of the column of 
air expelled by coughing. 

The lower animals are subject to attacks of diphtheria. Pigeons, 
turkeys, and cats have communicated it to the human family in vari- 
ous authenticated instances. Hence the unappreciated danger of 
allowing children to pet and caress sick cats is apparent. Rabbits 
and guinea-pigs are susceptible to the diphtheric virus, and cows' 
milk has been known to convey this disease, as it does scarlatina. 

Symptomatology. — There is a very wide margin of varieties in 
both the local and systemic manifestations of diphtheria. The disease 



DIPHTHERIA. 361 

may appear in a very mild form, or there may be a severe throat 
inflammation with distressing local symptoms and alarming and fatal 
constitutional disturbances. The period of incubation is generally 
from two days to a week, and is characterized by sensations of chilli- 
ness, waves of heat, headache, weariness or sleepiness, and depression 
of spirits. Following these premonitory symptoms are more pro- 
nounced ones announcing a serious involvement of the digestive and 
circulatory systems. Loss of appetite, nausea, vomiting, and diar- 
rhcea occur, accompanied by thirst and increase in the force and fre- 
quency of the heart's action. Heat and dryness of the throat, stiff- 
ness or soreness in the muscles concerned in the act of swallowing, 
which is painful: and tenderness on pressure under the angle of the 
jaw indicate the localization of the pathological process in the throat. 

The temperature rises to 101° F. in the first stage and some- 
times as high as 104° F. Adults are more likely to complain of 
headache and backache than children. An erythematous eruption 
occasionally appears during the first stage. Inspection of the throat 
within the first few hours of the seizure reveals a reddened, swollen 
condition of the mucous membrane of the soft palate and tonsils. All 
the symptoms are not present in every case. One must expect to find 
some of these lacking, and a description that will accurately fit one 
case may vary widely of the mark if applied to the next. But we 
would best consider typical cases. 

The second stage is that in which the false membrane is formed 
and the presence and proliferating powers of the diphtheria bacillus 
are demonstrated. The first appearance of this disease-label — which 
is usually within the first day or two of the onset — is a thick, yellow 
secretion, which can be seen covering the tonsils. A little later a 
yellowish-gray or a dirty, grayish-white, false membrane is seen to 
have made its appearance in the fauces and pharynx, increasing in 
thickness and extent until little can be seen but this reeking back- 
ground to a painful picture. If pieces of this adventitious tissue are 
detached from the mucous membrane, to which it is closely adherent, 
the latter is seen to appear rough, raw, granular, and bleeding. All 
the groups of glands in the vicinity of the throat become indurated 
and sensitive. 

The high temperature usually falls after the full development 
of the exudate in the pharynx, and may reach the normal on the 
fourth or fifth day. Decomposition of the secretions of the throat 
causes an offensive breath, which may often be observed the instant 



362 DIPHTHERIA. 

one enters the patient's room. The profound impression of the diph- 
theric virus on the circulatory system is evident from the feebleness- 
of the pulse, which is compressible and abnormally rapid or slow. 
The kidneys participate in the general systemic disturbance, although 
the diphtheria bacillus itself does not penetrate to them; and the urine- 
is decreased, high-colored, and rich in urea, and often in albumin 
also. 

About the third or fourth day there may occur an extension down- 
ward of the disease into the larynx with unmistakable signs of a 
serious complication. The respiration is harsh and embarrassed and 
a dry cough reveals the hoarseness of the voice. Increasing con- 
striction of the laryngeal cavity is evidenced by distressing dyspnoea, 
blueness of the lips and finger-nails, pufhness of the face, and in- 
creasing dullness of the intellect until unconsciousness and fatal coma 
come to the sufferer's final relief. 

Other complications result from an extension of the disease to 
the nasal cavities, followed by a thin, yellow or dark, foul discharge 
from the nose, excoriating the skin about the nostrils and on the 
upper lip. Invasion of the nasal ducts may lead to involvement of the 
eyes; or extension to the Eustachian tubes may presage invasion of 
the middle ears with the train of consequences following in the wake 
of a suppurative middle-ear inflammation of a diphtheroid type. 

The third stage results in resolution or death. This period of 
the disease begins at about the end of a w T eek, when all the racking 
symptoms may gradually melt away with the loosening and exfolia- 
tion of the false membrane. The general condition shows a refresh- 
ing improvement, — a sunshine of calm succeeding a physical storm. 
The fever is gone, the pulse drops to the normal rate, painful swallow- 
ing disappears, desire for food returns, the kidneys and skin perform 
their functions naturally, and all but the strength may now return 
to par. 

Unless a relapse occurs, or the heart has been too profoundly 
implicated so as to incur the liability of syncope, or diphtheric paraly- 
sis follow the attack, the patient pursues a normal course to complete 
recovery. 

In case the infection is of an intensely virulent type and finds 
the powers of resistance weakened, the system yields to the irresistible- 
invasion of the virus and succumbs to coma and death. 

This is the natural history of a typical attack of diphtheria un- 
influenced by the efforts of man to avert or modify its progress. Be- 



DIPHTHERIA. 363 

tween this type and simple membranous sore throat there are great 
variations in the vimlency of the infection and its manifestations. 

Diagnosis. — Simple membranous sore throat and ulcerative ton- 
sillitis are the most likely to confuse the practitioner in differentiating 
between diphtheria and other pharyngeal affections; but the exuda- 
tive form of sore throat in measles and scarlet fever also closely 
resemble true diphtheria. The presence of a diphtheric epidemic, 
the rapid development of the symptoms, and the closely adherent, 
leathery membrane are definite diagnostic features. The membrane 
of the other diseases is thin and easily wiped off with cotton, leaving 
generally a smooth membrane beneath, instead of a rough, ulcerating, 
or bleeding surface. The absence of the skin-signs of measles, scar- 
latina, and erysipelas aid in excluding those diseases, although very 
exceptionally an erythematous rash occurs in the first hours of diph- 
theria. 

From throat inspection alone it is impossible to distinguish be- 
tween diphtheria and other forms of pharyngitis before either a false 
membrane forms or an eruption appears, so that it is then necessary 
to be conservative in expressing an opinion, and to treat the case as 
though it were expected to eventuate in diphtheria. 

A positive diagnosis is possible if a bacteriological examination 
prove the presence of the Klebs-Lofner bacillus. Other microbes may 
be present and embarrass the results of treatment, but the nature of 
the infection is established. It must not be forgotten, however, that 
another micro-organism identical with the Klebs-Lofner bacillus, to 
all appearances, is sometimes found, but differing from it in that it 
produces a milder affection. The disease characterized by this mi- 
crobe should be termed "diphtheroid," analogously to the formation 
of the term "typhoid" from typhus. As soon as any symptoms exist 
to excite a reasonable doubt as to the possibility of the disease being 
diphtheria, the secretions, and especially any available false mem- 
brane from the throat, should be secured in a perfectly-clean, steril- 
ized test-tube and submitted to the microscope and culture-test by a 
competent bacteriologist whenever it is possible to do so. Where it is 
not practicable, the treatment should be conducted on antidiphtheric 
principles until a positive diagnosis can be rendered. 

Prognosis. — This is one of the most fatal of the diseases that 
afflict humanity: but, in view of all the evidence adduced, it is 
evident that the death-rate has been reduced since the introduction 
of serum-therapy. Xotwithstanding this, the physician should always 



364 DIPHTHEKIA. 

recognize the possibility of a fatal termination even under the most 
favorable circumstances for treatment. If the infection is of a mild 
type and the resisting-powers of the patient are strong, the chances of 
recovery are good. The majority of such cases get well; but one can- 
not tell when such a case may take on a virulent form of the disease 
that rapidly leads to collapse. 

Patients often succumb in a clay or two after the seizure, and 
the majority of fatal cases die by the fifth day. In very young chil- 
dren, at the age when tenacity upon life is feeble, this disease rages 
with a fearful mortality. Signs of the gravity of an attack are in- 
vasions of the nose, ears, larynx, and trachea; haemorrhages; purpuric 
eruption; suppression of the urine; vomiting, and diarrhoea. In laryn- 
geal stenosis without intubation or tracheotomy the death-rate reaches 
the appalling figure of 95 per cent. A large number of sudden deaths 
are attributed to heart-failure. 



CHAPTEE XXXI. 

DISEASES OF THE PHARYNX, CONTINUED. 

Diphtheria, Continued. 

Treatment. — Since diphtheria is primarily a local disease with 
secondary constitutional infection, in this respect comparable to syph- 
ilis, we will take up the consideration of medicinal treatment in the 
logical order suggested by the sequence of the phenomena that con- 
stitute its history: (1) local and (2) constitutional treatment, — both. 
the classic method and the modern serum-therapy. But coinciclently 
with the beginning of treatment certain preliminary precautions must 
be observed for the conduct of any given case to a successful issue, 
and also for the protection of other members of the family and the 
community. 

In addition to observing the patient's pulse, temperature, and 
respiration, and other physical signs and symptoms, the throat and 
nose should be examined in such a way as to avoid the possibility 
of the physician himself becoming infected. Instead of occupying a 
position immediately in front of the patient while inspecting the 
throat he should be at one side and on the alert to dodge any of the 
discharges from the throat that may be expelled by a sudden, ex- 
plosive cough. Otherwise a lodgment of the venomous secretion or a 
particle of false membrane in the doctors eye or on his lips may cost 
him his life. Moreover, cases have occurred in which the expulsion 
of the virus has resulted in its landing in the examiner's beard or on 
his clothing, and the communication of the disease with deadly effect 
to members of his own family or to other patients. The practice of 
holding a small pane of window-glass between the patient's mouth and 
the physician's face is an excellent one. 

The medical attendant of a diphtheric case would best remove 
his coat and vest and wear an operating-gown reaching from his neck 
to his feet, or, in lieu of this, a sheet pinned about his neck and en- 
veloping the person to the feet. After the examination, his hands, 
face, and beard should be washed with a solution of bichloride of mer- 
cury. 1 to 10,000. The instruments used should be boiled over a very 
hot fire in a solution of carbonate of sodium — an ounce to the pint 

(365) 



366 TREATMENT OF DIPHTHERIA. 

of water — to disinfect them. All utensils, handkerchiefs, napkins, 
etc., used by the patient must be treated in the same manner. 

Assuming that the examination reveals the presence of diph- 
theria, or even a condition that excites a suspicion of that disease, the 
patient must at once be isolated from all except the medical attendant 
and the nurse. If possible, one or two rooms should be selected away 
from any cellar or basement, above the ground-floor and so situated 
as to admit the sunlight and an abundance of fresh air. All carpets, 
rugs, window-curtains, pictures, draperies, upholstered furniture and 
unnecessary articles must be removed before the patient is admitted 
into this room. Without exposing the sick one to draughts of air, 
free ventilation should be effected from the tops, not the lower parts, 
of windows. The temperature should be kept uniformly at 70° 
to 74° F. The body-clothing must be such that children cannot 
expose themselves to cold at night, and this rule should be observed 
also at all times, with children especially, who ought to wear union- 
suits by day and night-drawers at night. These consist (the first) of 
woolen shirt and drawers in one piece and (the second) of cotton- 
flannel or cotton suits made in the same way. The woolen suits are 
to be used in winter and the cotton-flannel for cool, and the cotton 
for hot, weather. The drinking-water must be pure. If there is reason 
for the slightest suspicion of the purity of the water it should be 
boiled for fifteen minutes and then chilled, not by placing possibly- 
infected ice in it, but by setting it covered in a cold, pure atmos- 
phere in winter or surrounding it with ice in hot weather. Pure 
water made cold by this means is safer than the ice sucked, as recom- 
mended by many writers, since freezing does not destroy disease 
germs. 

The drainage of the house should be inspected to ascertain if 
cess-pools, stagnation, or faulty sewer connections are responsible for 
the sickness. All communication between the outside world and the 
patient must be forbidden, except through the physician and the 
nurse. In order that the contaminated air of the sick-room may not 
infect the adjoining apartments, a sheet should be saturated with a 
5-per-cent. solution of carbolic acid and hung over the door-way of 
the chamber. A valuable antiseptic procedure is to have the bedstead, 
floor, and walls washed daily with a solution of mercuric bichloride, 
1 to 10,000. One to 20,000 parts of water will destroy bacteria in 
ten minutes. 

The physician's duties do not end with giving instructions. He, 



TREATMENT OE DIPHTHERIA. 367 

himself, must often insist on their observation and personally super- 
intend or execute his own orders if he would save his patient's life. 
As an illustration of the indifference of the average family to the 
commonest sanitary regulations I will adduce a single instance: Upon 
being called to see a girl of IT years. I found sufficient clinical evi- 
dence to warrant pronouncing her ailment diphtheria. She was lying 
in a bed in a large, but dark. damp, and musty room. On inquiry it 
developed that her brother and father had died of the disease in the 
same room and in the identical bed. I immediately asked to be shown 
the rooms on the floor above, and selected two adjoining apartments 
extending the width of the house, so that windows admitted sunlight 
and air on opposite sides. I directed all the contents of these rooms 
to be removed, excepting nothing but a bed, a table without a spread, 
and a chair without upholstering. Promise was exacted that the pa- 
tient would be removed to these chambers without delay. On the fol- 
lowing day I found the patient where I had left her, and worse. Xo 
time was lost in informing the family that I would at once withdraw 
from the case, and that I would not make another visit or prescribe 
for the patient at the present time unless they immediately removed 
her to the selected apartments. They had decided that it would in- 
convenience them to do so, but they hastened to comply with my 
•demands. Thorough antiseptic measures were adopted, such as had 
not been employed in the cases of the brother and father. Another 
younger child, a sister of the patient, soon was suffering from the 
same disease. She was subjected to the same rigid hygienic measures. 
Both childen recovered. One had abscesses of the neck, but no per- 
manent bad results further than scars indicating the points of in- 
cision. Father and son died in the same room, in the same bed. with 
the surrounding conditions described. The two sisters recovered un- 
der conditions made as favorable as possible. Had they been kept 
in the dark, damp, musty, infected atmosphere of the double-death 
chamber, I predicted that the undertaker would soon follow my foot- 
steps. Measures that seem imperative and even harsh may sometimes 
be absolutely necessary to the patient's welfare and the doctor's con- 
science and reputation. 

It is a great advantage to have a skilled nurse to faithfully and 
intelligently execute the physician's directions. She will best carry 
out all the modern methods of care of the sick as perfected in our 
great hospitals. She will be prepared — as no untaught person cau 
be — to observe the aseptic and antiseptic teachings of advanced med- 



368 TREATMENT OF DIPHTHERIA. 

icine. Nothing that leaves the diphtheric patient, and that is capable 
of bearing infections material, should escape a most thorough, sys- 
tem of sterilization. Instead of napkins or handkerchiefs, cloths 
should be used to receive the matters expectorated, or discharges from 
the nose, etc., and these should be burned with the most scrupulous 
care that not a rag is left. The importance of this and the disin- 
fection of sputa is plain enough when we reflect that flies are at- 
tracted to such refuse, after visiting which they cultivate the ac- 
quaintance of your susceptible nose, lips, and eyes, or any point of 
skin denuded of its epidermis, and there inoculate your infectious 
point. Cats prowl around the backyard, into which cloths soiled by 
the diphtheric discharges are thrown. These cats contract the disease 
and distribute it throughout the neighborhood. Dame Nature, in an 
angry mood, seems to have exercised all her cunning and ingenuity 
to devise unsuspected ways and intricate and invisible means for the 
prolific production and wide dissemination of the germs of this fatal 
plague of the throat. Such considerations led J. Lewis Smith to say: 
"The day will probably never come when we can say of diphtheria, as 
we can of small-pox, that it is virtually suppressed/ 7 

The sputa should be disinfected, before removal from the pa- 
tient's chamber, by pouring over it enough of a solution of bichlo- 
ride of mercury — 1 to 1000 — to entirely cover the discharges. This 
should remain in the receptacle at least a half-hour and be agitated 
several times to bring all portions of the ejecta into contact with the 
disinfectant. Deodorizing and disinfecting medicaments are vol- 
atilized in the room, much to the patient's comfort. I have observed 
excellent effects from melting menthol crystals in a teaspoon over a 
name until the air was comfortably impregnated with the fumes. 
When the nose was involved I have taken the hot steaming liquid to 
the bedside and held it where I could blow the fumes over the bed 
toward the patient's face so that he would inhale a considerable 
quantity of them through both the nose and throat. His eyes are 
kept closed, and if not too great heat is used so as to make the fumes- 
too dense, without any irritating effects, his nose and throat are 
benefited. If the throat is entirely covered by a thick membrane, of 
course no fumes reach the mucous coat beneath. J. Lewis Smith pre- 
scribed as a prophylactic the fumes of the following prescription: 
^ Olei eucalypti, acidi carbolici, of each, gj; terebinthinss, gviij. 
"Add 2 tablespoonfuls of this mixture to 1 quart of water and allow 
it to simmer constantly near the patient in a vessel with a broad sur- 



TREATMENT OF DIPHTHERIA. 369 

face, as a tin or zinc wash-basin, a vessel with a broad surface being 
needed so that it will not take fire. The vapor produced is strong and 
penetrating, but not unpleasant.*' 

Local Treatment. — There are remedies that exert a solvent action 
on the false membrane when the latter is macerated in them for a 
considerable time, and this fact has led to their use as gargles and 
local applications by means of swabs and sprays. Some of these reme- 
dies have too slow and feeble an effect to be of efficient use in the 
throat. Others exert a decided and perceptible influence in dissolv- 
ing the exudate both without and within the body. Such, for ex- 
ample, is sulphocalcin, to which my attention was first attracted by 
William C. "Wile several years ago, at a meeting of the Mississippi 
Valley Medical Association, to which he reported a large series of 
diphtheric cases in which unusual success had attended the topical 
application of this remedy. I then introduced it into my practice, 
and am able to confirm Wile's statement of the solvent properties of 
this preparation. In a letter recently received from the doctor he 
reaffirms his previous statements, and says his experience during the 
intervening years has been as satisfactory in the use of the drug as 
his first reports indicated. 

My method of employing the liquid is as follows: Absorbent 
cotton is twisted firmly on a long cotton-carrier curved at the rough- 
ened end so that it is impossible for the pledget to drop off into the 
throat. This is dipped into the fluid and pressed against the side of 
the small container, which should have a wide mouth. After press- 
ing out all the surplus so that none will squeeze out and run down into 
the larynx, the medicated cotton is brought into contact with all the 
surfaces of the false membrane, making sure that the latter is wet with 
the sulphocalcin. The cotton is then burned. This treatment is 
repeated as often as is necessary to keep the membrane dissolved and 
the throat clear of it. At first it has sometimes been necessary to have 
the nurse apply it every fifteen minutes, lengthening the time between 
the treatments, as the membrane becomes less rapidly formed, to a 
half-hour, an hour, or two or four hours. "When no false membrane 
reappears the remedy is discontinued. The solvent effect of this 
treatment is so apparent that I wonder at its not having come into 
more general use. Its disagreeable odor is an unfortunate feature. 
John North informs me that a 30-gram solution of permanganate of 
potassium will dissolve the false membrane. 

In the British Medical Journal of recent date Lennox Browne 



370 TREATMENT OF DIPHTHERIA. 

speaks of sulphurous acid as being an efficient germicide that acts 
systemically as well as locally with good results. I have often applied 
the sulphocalcin pure, and always do when the false membrane is 
thick enough to prevent the remedy from coming into actual contact 
with the mucous surface; but, when the exudate is reduced to such 
a state of thinness as to allow the drug to penetrate to the mucous 
membrane beneath, it is necessary to dilute it with water until the 
smarting and burning otherwise produced is reduced to the point of 
toleration. But, the stronger it can be borne, the better the results. 

Hydrozone, or dioxide of hydrogen (peroxide, H 2 2 ), has proved 
very effective when it could be used in full strength with an atomizer. 
I have used large quantities of hydrozone during the past few years 
with great satisfaction. It is one of the best of disinfectants and 
antiseptics. When a spray of the fifteen-volume strength is made to 
copiously cover the false membrane it immediately begins to foam. 
As it comes in contact with pus-corpuscles they are decomposed and 
oxygen is liberated to destroy the micro-organisms present. The 
mechanical effect of the process of effervescence appears to make the 
false membrane more friable, to loosen it, and to aid in its removal. 
It is best to spray an abundance of the fresh preparation into the 
throat while the tongue is depressed, so as to reach every part of the 
pharynx. Then the patient, if old enough, is directed to hold it in 
the throat and gargle it so that contact is prolonged. Gagging should 
be avoided for fear of producing vomiting and the loss of much- 
needed food. The tongue-depressor must not be carried far enough 
back on the base of the tongue to cause retching. This treatment has 
proven very effective in my experience, and is repeated every half- 
hour, or every one, two, or four hours, as the conditions demand. It 
is of prime importance that the hydrozone be strictly pure, fresh, and 
just opened, and not allowed to be exposed to the air, heat, or light. 
If the pure hydrozone cause too much smarting, it can be diluted. 

For some years before sulphocalcin and hydrozone were intro- 
duced I used lactic acid in a steam-atomizer. It appeared to have a 
beneficial action in softening and loosening the false membrane. It 
is a favorite remedy with Lennox Browne, who applies it pure once 
or twice a day and has the nurse make applications of a dilution, 1 
to 6, every two or three hours. It is to be pressed into the false mem- 
brane with a cotton swab. This cotton-applicator should always be 
used instead of a brush, for the latter is sometimes laid aside and 
forgotten only to be used at some future time and add more sorrow 



TREATMENT OF DIPHTHERIA. 371 

and deaths to the account of diphtheria. Such instances are on record. 
When pieces of the diphtheric membrane are macerated in pure lactic 
acid outside the body it becomes "soft, translucent, and jelly-like." 

There is one objection to all applications that must be made with 
swab, brush, probang, etc. In the case of fighting, struggling chil- 
dren these methods probably do more harm than good by exhausting 
the little patient's strength. 

I have used the purple, or blue, pyoktanin, but am not satisfied 
of its value. From my experience with a 10-per-cent. solution of 
carbolic acid in glycerin in other diseases I am led to believe that 
its germicidal and local-anaesthetic effects would be valuable here. 
Lime-water irrigations and sprays have but little effect on the false 
membrane, but the direct fumes of slaking lime are beneficial, as even 
steam alone tends to soften and loosen the membrane. The lime- 
water makes the membrane more friable, but not thinner. I could 
never see any satisfactory results from potassium chlorate except sim- 
ply as a cleansing solution. Salicylic acid is highly recommended by 
some Europeans, but is not in favor with Americans as a local remedy. 
I have no experience with it in diphtheria, but the results of trials 
with it for similar purposes in other diseases are not reassuring. In- 
sufflations of powdered sulphur are much used by the laity, but I have 
seen no benefit, though much misery, from them. 

Tearing off the pseudomembrane and cauterizing the mucous 
membrane is to be deprecated. Its forcible removal is justifiable only 
when it amounts to an actual obstruction to respiration. It should 
be borne in mind that the bacilli are not in the layer next the mu- 
cous membrane, but in the superficial layers. Generally they are not 
found to have penetrated to the mucous membrane, — a fact that 
seems to have been lost sight of by those physicians who aim to pene- 
trate the deeper layer of the false membrane in order to inject reme- 
dies into the mucous tissues beneath, which opens up an avenue for 
the penetration of germs to the blood- and lymphatic vessels. 

J. Lewis Smith reported excellent results from the following 
prescription for topical application: — 

R, Acidi carbolici, gtt. x. 

Liq. ferri subsulphatis, f 3iij. 

Glycerini, f§j. 

Aquae purse, f^ij. 

Lofner (Deutsch. med. Woch., October 18, 1894) gave to the Buda- 
pest Congress his formula for toluol for the local treatment of diph- 



372 TREATMENT OF DIPHTHERIA. 

theria. It consists of alcohol, turpentine, and 2-per-cent. phenol 
(proportions not given). Since then he has used the following form- 
ula: Alcohol, 60 volumes; toluol, 36; liq. ferri chloridi, 4. In 71 
cases in private practice he had no deaths; adding 30 cases in hos- 
pital with 5 deaths makes a mortality of 4.9 per cent. 

The local applications of toluol "should be begun early, should 
be thorough, and should be repeated every three or four hours until 
the temperature sinks to normal, which usually occurs in from twenty- 
four to forty-eight hours. Afterward three times daily and continued 
as long as any membrane is present." 

Loffler claims that if this application is used often enough and 
thoroughly the disease does not spread and has not invaded the nose 
or larynx in any case so treated. Intense pain followed the applica- 
tion, so "20 volumes of menthol were added, making: menthol, 20 
volumes; toluol, 36; absolute alcohol, 60; liq. ferri chloridi, 4." 

When the nose is invaded, a spray of dioxide of hydrogen, 1 
part in 5 or 10, if it smarts, or DobelPs alkaline antiseptic solution, 
the formula for which is given in the appendix, should be sprayed 
into the nose until it is cleansed. Then the nares are cleared by 
blowing or by cotton on the small carrier (Fig. 9), and aristol is in- 
sufflated by means of the small powder-blower (Fig. 198). 

Cold applied continuously to the throat with ice-bags (Fig. 83) 
retards and modifies the intensity of the inflammatory action of the 
first stage, but, after the false membrane begins to separate, con- 
tinuous heat is indicated. The hot applications may be better borne 
than ice in the first stage, and if cold appear to produce discomfort 
and irritation the heat should be substituted. Water as hot as can 
be comfortably borne may be used in the same rubber bags. 

Acids retard the proliferation of micro-organisms, and for that 
reason lemon-water and cold water acidulated with the acid phosphate 
or dilute sulphuric acid are of service and grateful to the patient. 
If the sulphuric acid is used it must be taken through a glass tube 
and must not be allowed to come in contact with the teeth, on account 
of its deleterious action on the enamel. Frozen milk and beef-tea 
cool the throat, quench the thirst, and support the strength. Barley- 
and rice- water are to be recommended in the same way and for the 
same reasons. 

Internal Treatment. — The patient should be persuaded to take 
milk in preference to water for quenching the thirst and for the sake 
of maintaining the strength. Insistence may need to be resorted to for 



TEEATMEXT OF DIPHTHERIA. 373 

the sufferer's good. "When the strength begins to wane alcoholic stimu- 
lants are necessary to bridge over the period of exhaustion and conse- 
quent collapse. Whisky, sherry-wine, or diluted alcohol in emergencies 
are mostly to be preferred. Stimulation and alimentation by enemata 
may be required when swallowing is impossible or the stomach rejects 
everything. Preparations of predigested foods, peptonized meat. etc.. 
can be injected into the bowel per rectum through a large catheter 
extending well up toward the sigmoid flexure. 

Tonics are indispensable in severe cases. Quinine and iron are 
the favorites of most physicians unless heart-failure is impending. 
when strychnine is employed. Tincture of the chloride of iron is 
given in large doses every two hours, proportioned to the patient's 
age. It is best combined with glycerin, as, for example, in Billington's 
formula: R Tincturae ferri chloridi, foj; glycerini, aquae, of each, 
fgj. Mercury in the form of the bichloride and the mild chloride 
has for a long time been in high repute with the profession both in 
Europe and America. The corrosive sublimate is used in solution — 
1 to 10,000 — locally, and considerable doses in the form of pills, etc., 
are also given internally. The calomel is administered internally and 
by sublimation. Internally it is given in doses of 1 / 2 to 3 grains 
every two hours until the bowels move freely, and then the doses are 
placed at sufficient intervals to not weaken the patient by catharsis. 
ATlien the membrane is discharged, the calomel is discontinued. I. 
X. Love uses sodium benzoate in doses of 5 to 15 grains. Guttmann 
and others claim good results from pilocarpine, but its depressant 
action on the heart and the bronchorrhcea it produces render its effi- 
cacy at least questionable in a disease with a natural tendency to 
heart-failure and respiratory obstruction. In case of enfeebled heart- 
action full doses of strychnia are indicated. 

Treatment for laryngeal invasion will be found in the division 
on the larynx (page 461). 

Apartments occupied by diphtheric patients must always be thor- 
oughly fumigated with sulphur as soon as recovery takes place. Dry 
fumigation is not sufficient. In order to effectually destroy disease 
germs the air must be kept moist during the process of fumigation. 

Paralysis of the larynx, pharynx, velum palati, and lower ex- 
tremities and loss of the tendon reflexes are sequels of diphtheria. 
Strychnine in large doses, especially subcutaneously injected: cen- 
tral galvanization; and local faradization have given the best result- 
in overcoming these paralyses. 



374 TKEATMENT OF DIPHTHERIA. 

The antitoxin, or blood-serum, therapy, already mentioned, is 
considered in the following chapter. 

Intubation is treated of under a separate heading (page 464). 



CHAPTER XXXII. 
DISEASES OF THE PHARYNX, CONTINUED. 

Diphtheria, Continued. 

serum-therapy in diphtheria. 

Behring, Kitasato, Roux, Ehrlich, Martin, and others have 
found, as a result of their experiments, that if the blood-serum of 
animals that have been deprived of susceptibility to a certain dis- 
ease be injected into other animals, it deprives the latter, in turn, 
of susceptibility to that disease, and modifies or aborts the disease if 
it be already present. Rabbits and guinea-pigs are employed in these 
experiments. If the serum from one of these animals previously 
immunified against diphtheria or tetanus be injected into another 
susceptible one, the latter is protected from the given disease for a 
time. 

The method of procedure in these experiments is, briefly, as 
follows: Enough of the poisonous product of the disease is injected 
into an animal to sicken it, but not to cause death. Small hypoder- 
mic injections of diphtheria cultures and toxins are given at first 
and gradually they are increased as the tolerance of the animal in- 
creases. As this process proceeds the blood of the injected animal 
acquires gradually increasing immunifying powers. The injections 
are followed by local tumefaction and fever. At intervals a quantity 
of blood is taken for the purpose of experimental tests on other ani- 
mals to determine its efficacy. After the latter is shown to be suffi- 
cient, a large amount of blood is taken from the animal, placed in 
vessels on ice to produce coagulation, and the separated serum, mixed 
with 1 / 2 of 1 per cent, of carbolic acid, constitutes the serum remedy. 
On account of their susceptibility and size, goats and horses are em- 
ployed to obtain this serum in large quantities. An enormous amount 
of this is produced in Germany. Behring says: "The works can now 
supply one hundred thousand doses a month, which barely keeps pace 
with the demand from Europe and America." 

The benefit to be derived from the antitoxin injection depends 
largely upon the time in the history of the disease at which the 

(375) 



376 SERUM-THERAPY IN DIPHTHERIA. 

remedy is employed. If three or four days or a longer time lias 
elapsed, so that the disease has invaded the larynx or bronchial tubes, 
and the profound toxic effects of the diphtheric poison are mani- 
fested in the heart, nothing may save. If the building is nearly con- 
sumed by fire, water cannot save it. However, the patient should 
always be given the benefit of a doubt and the remedy that promises 
the most hope must be used. 

The German physicians report a large saving of life by the use 
of the serum-therapy. Eoux, of Paris, claims similar results. It is 
asserted that the serum itself is harmless, and some deaths that have 
followed immediately upon the injections may have been due to other 
causes, such as the syringe penetrating a vein and injecting air, or 
heart-failure, etc. Other deaths may have been caused by the acci- 
dental introduction of some other material of a. septic nature. The 
varying results apparent in the statistics of different observers and 
hospitals are likely affected to a considerable extent by a difference 
in the virulence of the several epidemics and of different cases in the 
same epidemic. 

In reviewing the subject of blood-serum therapy, or antitoxin 
treatment, with a view to fix its present status and to place a just 
and impartial estimate upon its actual value in diphtheria, I have in- 
vestigated the current literature on the question down to the present 
time, and shall offer the evidence on both sides. The reader would 
best assume a judicial attitude and decide according to the law and 
the evidence as they are presented by the several able advocates. 

The serum injections are made in the loose subcutaneous tissue, 
generally below the axilla or between the shoulder-blades, after pre- 
paring the skin by washing with soap and a bichloride solution, 1 to 
1000. The antitoxin of Behring comes in hermetically-sealed flasks or 
vials bearing labels that indicate the doses contained. Each vial 
contains one dose, as follows: No. 1, 600 immunizing units, to be 
used on the first or second day of the attack; No. 2, 1000 units, for 
serious cases on first or second day or in mild cases of longer dura- 
tion; No. 3, 1500 units, for adults or severe cases in children. If 
one injection does not prove effective, it is repeated after twenty-four 
hours. 

As a prophylactic, smaller doses are given. For children, 100 to 
200 units are sufficient. The length of time this dose affords im- 
munity is not definitely known, but it is safest not to allow more than 
three weeks to elapse with a child still exposed to the disease without 



SERUM-THERAPY IN DIPHTHEKIA. 377 

a repetition of the protective dose. An extended treatment of this 
subject may be found in an excellent monograph entitled "Blood- 
serum Therapy and Antitoxins/ 7 by G. E. Krieger, Chicago. 

AVe will now consider the results of the blood-serum therapy. 

Behring announces that the close of 60 units, at first considered 
sufficient, is too small for some cases, and that 150 units had better 
be given in all cases. Even this dose is not always sufficient when the 
infection is virulent and the period of incubation nearly over. In 
such cases a full dose of No. 1 (600 units) may not be sufficient to 
prevent the development of the disease. An attack following the in- 
jection is usually mild. In 10,000 cases immunized only 10 con- 
tracted diphtheria. The antitoxin is excreted by the kidneys, and 
immunity depending on it ceases when all is eliminated. The larger 
the total dose, the longer the immunity, and smaller doses at intervals 
are more serviceable than one large dose. 

Professor Behring has replied to the critics of antitoxin, and sup- 
ports the efficacy of this discovery by innumerable statistics (Deutsch. 
med. Woch., 1895, No. 38). He claims that even statistics do not do 
it justice, as it is used in perhaps the more desperate cases, and the 
mortality percentage is, therefore, higher than it should be in pro- 
portion. But, even allowing for countless errors, the percentage is 
a great gain over. the. past. The mortality in Berlin in 1895 sank to 
15 per cent., two-thirds less than it had averaged during the seven- 
teen years preceding, while the character of the diphtheria was more 
serious than at any time since 1886. Of 10,312 cases, 5833 were 
treated with serum, with a loss of 9.6 per cent., while 3479 cases 
treated without it showed a mortality of 14.7 per cent. The per- 
centage fell to 10.3 per cent, in the Contagious Disease Institute, 
where the serum was exclusively used. 

He asserts that the question now is: Shall it be used to secure 
immunity? For this purpose he recommends one-half of a regular 
dose. Improved methods have enabled the dose to be concentrated 
from 5 cubic centimetres into 1 cubic centimetre. In this connec- 
tion he expresses regret that the specific for tuberculosis is not yet 
all that was hoped for it, but congratulates Ransom on his cholera 
serum and Knorr on his for tetanus. 

"Professor Behring delivered a recent address on this subject in 
which he replied to the swarms of critics who have been attacking him 
the past year or so. He maintained that statistics prove the efficacy 
of the serum, and that the 60,000 deaths from diphtheria which the 



378 SEEUM-THEEAPY IN DIPHTHEEIA. 

German empire has averaged each year will be found to be reduced 
to 40,000, and a more general use of the serum would reduce this to 
one-third. Throughout the city of Berlin the fatality in diphtheria 
amounted to 30 per cent., but in the Contagious Hospital, where 
serum was promptly used, the mortality was only 20 per cent. In 
the same time in 1895 it was only 10.3 per cent. The mortality in 
the hospitals had always been much greater than outside heretofore. 
Last year the percentage of mortality in diphtheria cases in Berlin fell 
to 15 per cent. During this period the disease was not a mild form, 
but averaged more morbid symptoms than at any time since 1886. 
During the first three months of 1891, when the serum was not to 
be had, there were 363 deaths per 1000, while the last three months, 
when everybody could get the serum, there were 198 deaths per 1000." 
(Journal of the American Medical Association.) 

"Kossel, speaking for Koch and of the results obtained in the 
Institute for Infectious Diseases at Berlin, declares that no uncom- 
plicated case that was treated in the first or second stage of the disease 
was lost, and that the mortality of all cases was reduced to 16 per 
cent." (Sajous's "Annual of the Universal Medical Sciences.") 

Kossel, after using cow-serum, reported 117 cases of diphtheria 
with 13 deaths, or 11.1 per cent. He concludes that "one cannot ex- 
pect to cure every case of diphtheria with serum, but that with a 
sufficient dose recovery will follow with certainty in all cases of fresh, 
uncomplicated diphtheria. The prognosis is also much better, even 
in the later stages of the disease, than without the serum treatment." 

The use of antitoxin is highly extolled by the French. M. Monod 
claims that its use has decreased the mortality from diphtheria 65 
per cent., and it is claimed that by its use 15,000 lives in France have 
been saved. 

"In the Hopital Trousseau (Med. Press) during October and No- 
vember, 1894, 302 children were admitted to the 'doubtful wards/ 
and were at once injected with 20 cubic centimetres of serum. Later, 
53 were recognized as not diphtheria, and remained in these wards 
until recovery, none contracting diphtheria. Two hundred and forty- 
nine children were admitted to the diphtheria wards, and at the ex- 
piration of Moisard's term 18 were still under treatment. Of the 
remaining 231, 34 died, or a mortality of 14.7 per cent. As sequels 
of the serum-therapy there were, in all, 14 cases of urticaria, 9 of 
scarlatiniform erythema, 9 of polymorphous erythema, and 1 of pur- 
pura. 



SERUM-THERAPY IN DIPHTHERIA. 379 

"In the Hopital cles Enfants Malades, Paris, there was a reduc- 
tion of mortality by serum-therapy in 448 eases to 24.33 per cent. 
as against 51.71 per cent, for 39 Tl eases occurring from 1890 to 
1894. In no case was there any untoward result that could be ascribed 
to the treatment except slight urticaria. The beneficial effects of the 
serum were a marked improvement in the general condition; a cessa- 
tion of the growth of membrane within twenty-four hours, and dis- 
appearance of the membrane after thirty-six to seventy-two hours, 
with rarely a longer persistence; a return of the temperature to nor- 
mal; a diminution of the amount and frequency of albuminuria: and 
the appearance, less often, of such diphtheric sequelae as paralyses." 
etc. ("American Year-book.'*) 

"Kitasato, of Tokio, has collected from reliable sources 26.521 
cases of diphtheria in Japan previous to serotherapy, with 14,996 
deaths (56 per cent.): while in 353 cases treated here from Xovember, 
1894, to Xovember 25, 1895, there were only 31 deaths (8.78 per 
cent.). There is reason to believe that the mortality can be lowered 
if the treatment could be commenced early in the course of the dis- 
ease. Thus, in 110 cases in which injections were made within forty- 
eight hours after the invasion all ended in recovery. On the other 
hand, of 33 cases treated after the eighth day of the disease 11 were 
lost. Some of the patients were brought into the institute in a mori- 
bund condition: 6 children died within five hours after admission: 
6 more within ten hours; altogether 21 cases (two-thirds of the total 
mortality) were lost within the first twenty-four hours. As to. the 
effects of the serum on the course of the disease, the points to be noted 
are: 1. The fall of temperature; in many places the defervescence was 
almost critical, and it takes place usually at the end of twenty-four 
to forty-eight hours. 2. The separation of the false membrane, which 
takes place, as a rule, after the return of the temperature toward the 
normal. Very large casts of the trachea and larger bronchi have been 
coughed up. 3. Urticaria-like eruptions were observed in very many 
cases, being, in some, quite severe and annoying. They, however, 
disappeared in a few days without any treatment. 4. In 4 cases marked 
albuminuria was observed at the time of admission. In these cases 
albumin disappeared from the urine in the course of the treatment. 
Pyrexia was accompanied by albumin in the urine, but there was no 
reason to believe that any renal trouble was caused by the injections. 
5. Five cases developed paresis of the soft palate. Microscopic as 
well as culture examinations were made in every case, and Dr. Ivita- 



380 SERUM-THERAPY IN DIPHTHERIA. 

sato's report deals with those cases only in which Lofner's bacilli were 
demonstrated to be present." {Journal of the American Medical 
Association.) 

H. Gradle writes as follows: "Of a total of 3311 cases collected 
by Behring from the health reports in Berlin, in 1895, since the gen- 
eral use of antitoxin, 16 per cent, died, while according to previous 
experiences in the same places and by the same observers the mortality 
had been from 31 to 36 per cent. The death-rate is not the same in 
different cities and among different classes of the population, but, 
whatever it has previously been, it was always diminished by the new 
treatment. There is not a single record of any observer who has seen 
a sufficient number of patients to draw statistical inferences but what 
confirms the life-saving effects of the antitoxin treatment. ISTo such 
evidence has ever been brought forward to prove the efficacy of any 
other treatment in diphtheria, and those physicians who speak boast- 
fully of their time-honored remedies in their own hands cannot ad- 
duce the testimony of others in favor of their pet medicines, as no two 
text-books formerly agreed on the treatment of diphtheria. 

"Does the use of antitoxin involve any danger? A few deaths 
have been reported as occurring soon after the use of the remedy. 
But no observer who is familiar with the treacherous nature of the 
disease and the sudden heart-failure which sometimes occurs even in 
the mildest forms of the diphtheria can be convinced that antitoxin 
is responsible for these deaths. It was simply used too late to prevent 
them. An unpleasantness, but not a real danger, which has, however, 
been observed in about 5 per cent, of the cases treated, is a slight 
feverish disturbance, sometimes with pains in the joints or a rash on 
the skin. This incident, which has never proved serious, is insignifi- 
cant in proportion to the positive danger of the disease which the 
treatment reduces. 

"The prevention of diphtheria by means of antitoxin given after 
exposure to the disease, but before it has broken out, has likewise 
proved an unqualified success. Observations in children's hospitals 
and orphan-asylums, particularly in New York City, have shown this. 
Epidemics which in former times could be checked in such institu- 
tions with difficulty, and only by persistent quarantine of all the in- 
mates, have been stopped promptly within the last year by the pre- 
ventive use of antitoxin. The experiences of the physicians acting 
for the Chicago Board of Health have also confirmed the utility of 
the preventive treatment in checking the spread of the disease in 



SERUM-THERAPY IX DIPHTHERIA. 381 

(They confirm these reports at the pres- 
ent time.) 

Karlinski, as a result of a careful series of experiments on his 
own person, concluded that the diphtheric-heilserum influences in no 
way the metabolism of a healthy organism, and that the albuminuria 
in diphtheric cases treated with antitoxin should be ascribed to the 
disease rather than to the remedy. 

Foster (Medical News) says: "Of 2740 cases, including those 
requiring tracheotomy and intubation, treated with antitoxin, 509 
died,— 18.5-1 per cent. Of 4145 cases not treated with antitoxin 201? 
died, — 15.36 per cent. All the cases recovered when the antitoxin 
was injected on the first day of the disease; 2.83 per cent, died when 
the injections were begun on the second day; 9.99 per cent, when 
the first treatment was on the third day; 20 per cent, died when the 
first treatment was on the fourth day; 33.33 per cent, when the in- 
jections were begun on the fifth day; 811, or 38 per cent., when they 
were begun after the fifth day." 

Edwin Eosenthal says: "The antitoxin serum is used as a cura- 
tive or immunizing agent by subcutaneous injection into the tissues 
of the body. The parts chosen were in the back between the scapulae, 
on either side of the vertebral column, though other parts of the 
body, as the loins, groins, or the side of the chest, have been selected. 

"The parts were cleansed with alcohol soaked on sublimate cot- 
ton or gauze, the injection was made at one time with a suitable 
syringe, and after injection the parts were soaked with iodoform 
collodion. 

"The quantity injected depended upon the severity of the case 
and the day of the disease when the injection was made. If in the 
first two days and the disease mild, 600 units were injected. If, how- 
ever, the case were more severe, as in the lanmgeal variety, or after 
two days, 1000 or 1500 units were injected. These injections were 
repeated, if necessary, in twelve to twenty-four hours. After injec- 
tion, if the pulse and temperature declined, no more antitoxin was 
given; but, if the symptoms continued or became more urgent, larger 
quantities of the serum were injected until the characteristic decline 
took place." 

Eosenthal chose his dosage in units for the reason that so many 
different antitoxins were sold. He had used Behring"s, Aronson's. 
Gibier's, Koux's, Solis-Cohen ? s, and Mulford's, and each variety rep- 
resented a different strength. 1 cubic centimetre (about 15 drops) 



382 SERUM-THERAPY IN DIPHTHERIA. 

representing 60, 100, or 150 units; it was, therefore, easy to use the 
required dosage if the strength of the antitoxin were known. For 
instance, an injection of 1000 units of Mulford's antitoxin would re- 
quire 10 cubic centimetres at a dose, and so on. A total of 222 cases 
with 13 deaths showed a mortality of 5i| per cent. Of the 84 laryn- 
geal cases, 12 died; 31 were intubated, with 5 deaths. 

.Rosenthal's conclusions were: "Antitoxin is a specific in diph- 
theria; but, while acting specifically, it is not a cure-all, and other 
treatment must be pursued, as indicated by the special case. The 
earlier the antitoxin was used, the more certain was its success." 

R. H. Babcock, in the President's Address before the Tri-State 
Medical Society, in Chicago, spoke as follows: "The crowning achieve- 
ment in this line of work has come through the chemistry of bacteri- 
ology. Nuttall conclusively demonstrated in 1888 the power pos- 
sessed by the blood-serum of combating the poisonous products of 
bacterial growth, but to Behring and Kitasato, in 1891, belonged the 
credit of having found a practical means of utilizing antitoxins in the 
treatment of diseases." To those who decry the antitoxin treatment 
of diphtheria as dangerous and its advantages as not yet proven, Bab- 
cock commended the criticism by Welch in the Johns Hopkins Bul- 
letin of October, 1895. Welch's analysis of cases treated and published 
up to that time, in the opinion of Babcock, "sets at rest all doubt 
concerning the great reduction in mortality accomplished by this 
treatment, and renders the physician culpable who refuses this remedy 
to his patients." 

Rosa Engelmann, of the Chicago Health Department, in detailing 
the results of her experience with antitoxin says: "Seven deaths in 
103 cases, or 6.97 per cent., is a very low death-rate, especially if one 
consider that 50 of the 103 cases, or almost 50 per cent., were croup, 
— the most dangerous form of diphtheria. Doubling this death-rate 
to 14 per cent, for the laryngeal cases, still leaves a remarkably low 
mortality. This brilliant record is due to the fact that 91 of the 
103 cases were injected within the first three days." (Medical 
Standard.) 

Hare (Therapeutic Gazette) indorses serum-therapy, but em- 
phasizes the necessity of not omitting other treatment. "Three 
things are important to know when using antitoxin: 1. That a single 
dose of antitoxin is not always sufficient to counteract the poisonous 
infection. 2. While it may counteract. the results of the Lofner ba- 
cillus, it does not prevent its continued growth at the site of infection, 



SEROI-THERAPY IN DIPHTHERIA. 383 

— throat, nose, etc., — and the patient may still be dangerous to infect 
others even alter all the usual traces have disappeared. 3. It does 
not combat other infection, as the streptococcus or the like; it may 
prevent it if used early enough; but other treatment must be used 
in conjunction to make a favorable result." (Charlotte Medical 
Journal.) 

The majority of the members of the American Pediatric Society, 
at its meeting in May, 1896, were of the opinion that the effects of 
the serum-therapy in diphtheria justified an extensive trial. The 
same opinion prevailed in the Association of American Physicians. 

John Winters Brannon, physician to the "Willard Parker Hos- 
pital, Xew York (International Medical Magazine), says: "I must 
admit that I am as yet unable to range myself either among the 
enthusiastic advocates of diphtheria, antitoxin or with those who un- 
qualifiedly condemn it. Perhaps, if I touch upon some of the clinical 
features of diphtheria as modified by the administration of antitoxin 
in the Willard Parker Hospital, the reasons for my position may be- 
come apparent. 

•'Among the favorable results claimed to follow upon the injec- 
tion of antitoxic serum are a prompt improvement in the general con- 
dition of the patient, a strengthening of the action of the heart, a 
fall of the temperature, a rapid disappearance or 'melting away' of 
the membrane in the throat, and marked relief of laryngeal stenosis. 
I have already said that I believed that antitoxin often had a favorable 
effect upon the laryngeal symptoms, and I am inclined to think that 
this is especially true of the intubated cases, which seem to do better 
under antitoxin than without it. On the other hand, I have failed 
to note any effect, favorable or otherwise, upon either the pulse or 
the temperature, nor have I ever seen any mielting away' of the mem- 
brane which is not also observed in cases which have not received 
antitoxin. There is a case now in the wards in which the membrane 
has persisted for three weeks, although antitoxin was given on the 
third day of the disease. The general condition has also usually re- 
mained unaffected, except as it might be influenced by the relief of 
laryngeal stenosis referred to above. 

"Xow as to the alleged untoward effects of antitoxin. It has 
been said to cause nephritis, or, at least, albuminuria, and to favor 
post-diphtheric paralysis, or dissolve the red cells of the blood, and to 
set up septicaemia in some manner as yet unexplained. In regard 
to all these clinical phenomena, I can only say that I have failed to 



384 SERUM-THERAPY IN DIPHTHERIA. 

observe them, though. I have looked for them clay by day, particu- 
larly during the past eight months. Cases have shown albuminuria 
as in previous years, and, in the opinion of one of the resident staff, 
rather more than formerly, but casts or other evidence of nephritis 
have been absent. Suppression of the urine occurs, but not with 
unusual frequency. With the exception of simple regurgitation due 
to temporary paresis of the palatal muscles, I should say that post- 
diphtheric paralysis has been noteworthy by its absence during the 
present year. With regard to the destruction of the red cells of the 
blood or the occurrence of septicaemia, I have seen nothing which 
would lead me to attribute either of these morbid processes to the 
administration of antitoxin rather than to the diphtheric poison itself. 
Among the hundreds of cases treated this year in the hospital, there 
is but one in which, in my opinion, antitoxin may have contributed 
to the fatal termination. In the case in question, a severe one at the 
outset, a synovial inflammation developed in several joints some ten 
days after the injection of serum, coincidently with an urticarial erup- 
tion covering the legs and trunk. The fluid in the joints became 
purulent and the signs of broncho-pneumonia were found in the lungs. 
After a protracted illness the child died, and, on autopsy, in addition 
to the pus in the joints and the pulmonary consolidation, there was 
found marked fatty degeneration of the heart and kidneys. This case 
would probably have died from other complications, but we cannot 
but associate the joint process with the giving of antitoxin." 

In the Journal of the American Medical Association, B. Becker 
quotes as follows: "Koerte says: 'Bacteriologists say that antitoxin, 
if early used, will almost surely cure the genuine diphtheria. They 
wish those cases excluded which are complicated by the presence of 
other bacteria or cocci. In regard to this, I must say that we, as 
practitioners, when we talk about cure and treatment of diphtheria, 
must keep in view the clinical symptoms and appearance of the dis- 
ease, and that under this well-known and fully-characterized picture 
also those cases belong which are described as mixed infections. 
Every physician will declare such a case a severe one of diphtheria. 
From this point of view it is at this time not probable yet that anti- 
toxin will cure all cases of diphtheria, in a broader sense. Also the 
assertion that in an early and sufficient use of the serum all cases 
of genuine diphtheria can be cured is not proved yet. There is the 
possibility that in various epidemics those cases of mixed infection are 
so frequent that they may make a limit for the use of the serum. 



SERUM-THERAPY IN DIPHTHERIA. 385 

In spite of the rather favorable results which I have related, a longer 
continued observation at the bedside only can bring a decision as to 
the value of the antitoxin/ " (Berlin, hlin. Wochenschrift.) 

A discussion of the antitoxin was brought up at the Medical As- 
sociation of Munich, after the hearing of reports of cases by Bucher, 
von Banke, Seitz, and Emmerich. The following resolution was 
unanimously adopted by the association: — 

"1. To give a positive opinion about the value of Behring's serum 
is not possible at this time, especially on account of the differences 
of diphtheria in regard to appearance and severity of the disease; 
only a longer and closer observation can have a positive effect. It 
must be recommended, therefore, not to expect an absolute panacea, 
which suggestion should be given to the public also. 

"2. Our experiences with the antitoxin are of such a kind that 
we consider it worthy of further investigations and trials, especially 
in clinical and polyclinical institutions, as those places are the most 
fit for such experiments." (Munchener medic. Wochenschrift.) 

The opposition to the serum-therapy finds an advocate in Lennox 
Browne ("Diphtheria and its Associates," 1895), who claims as a re- 
sult of his experience with the antitoxin: "A greater number of chil- 
dren have been found liable to attacks of cyanosis and fainting, with a 
correspondingly-increased demand for nervines and stimulants. Com- 
plete recovery is, for the most part, delayed, and an unexpected fatal 
result at a late period is more frequent. When drawing attention at 
a meeting of the Clinical Society, last December, to an increased lia- 
bility to the most grave complications of diphtheria — viz., anuria, 
nephritis, and cardiac failure — under the use of serum we took occa- 
sion to express a hope that further experience might prove that the 
disadvantages of serum would be more than outweighed by its bene- 
fits." In 1000 cases, with 28-1 deaths, as compared with the earlier 
methods of treatment, he says: "The actual mortality was the same, 
— namely, 27. It was 27.10 on the whole number — 1163 — treated 
during the year 189-1 at the hospital whence our comparisons were 
made. 

"The foregoing observations as to the effects of serum treatment 
will, we trust, have made it clear that the injection of antitoxic serum 
into a patient attacked by diphtheria is not altogether free from an 
added danger, notwithstanding that the amount of active principle 
administered can be measured only by millionths; and we have seen 
that the power of this serum to do good and, per contra, its capacity for 



386 SERUM-THERAPY IN DIPHTHERIA. 

inflicting injury, is in proportion to the duration of the disease, — in 
other words, to the degree of the toxsemia. 

"As a corollary, we might be able to pronounce that the power 
of antitoxic serum to act as a prophylactic against a possible attack 
of diphtheria is in proportion to the rigor and healthy blood condi- 
tion of the individual in whom it is employed; but the very minute 
dose administered for this purpose is evidently capable of being soon 
broken up by cellular action in the healthy. 

"We can, therefore, understand the general admission as to the 
evanescent character of the immunity so obtained. Moreover, reports 
of cases are not wanting in which noxious and even fatal results have 
followed the use of serum when employed as a prophylactic. 

"On all these grounds, therefore, we do not feel justified in rec- 
ommending serum for this purpose. More real methods of preventing 
the spread of diphtheria are to be found in improved sanitation, in 
prophylactic surgical treatment already detailed, and in efficient isola- 
tion and disinfection." 

Kassowitz (Wien. med. Woch., Nos. 5 to 8) opposes serum-therapy 
for the reasons that "Attempted immunization toward diphtheria has 
failed repeatedly; relapses have occurred in children treated in the 
first attack with antitoxin; injection on the first or second day has 
not always averted a fatal issue, death in some cases occurring as a 
result of the diphtheric toxin; post-diphtheric sequels seem as fre- 
quent as formerly; the antitoxin has no sudden antipyretic action; 
the membrane does not seem to be loosened earlier or its formation 
checked; and the total mortality for diphtheria in Berlin has not 
been lowered." 

Hagenbach (Corresp.-olatt fur Schiveizer Aer.) used Behring's 
heilserum in a severe case of diphtheria with the following results: 
"Three days after the injection petechia broke out on the neck and 
spread over the whole body, vomiting set in on the seventh day, and 
death occurred on the tenth. The autopsy showed hemorrhagic gas- 
troenteritis, a high degree of fatty degeneration of the heart, and 
parenchymatous nephritis." 

Winters (Medical Record) opposes the serum treatment, declaring 
that, during an experience of three months in the Willard Parker 
Hospital with one hundred and fifty-four cases treated by it, "In not 
a. single case has there been the least evidence that the formation of 
the pseudomembrane was checked, that the exfoliation of the pseudo- 
membrane was hastened, or that the throat was free from the mem- 



SERtni-THERAPY IN DIPHTHERIA. 387 

brane earlier than in the cases that have not been treated by anti- 
toxin. In not a single septic case has the antitoxin made the least 
impression on the symptoms. The toxaemia has not in one instance 
been relieved or lessened. There has been no indication, in the char- 
acter or frequency of the pulse or in the general condition of the 
patient, that a specific for the toxaemia had been administered. The 
antitoxin is, therefore, opposed, first, because it does not neutralize 
the toxaemia nor favorably influence any of the clinical manifesta- 
tions of diphtheria, and, second, on account of its immediate danger 
to life through its influence on the kidneys and on the nervous sys- 
tem, and, remotely, through its influence on the blood.' 7 

Strueh (Journal of the American Medical Association) opposes 
antitoxin therapy and cites the unreliable character of statistical in- 
formation, instancing the variations in mortality in the Children's 
Hospital at Basel. In 1876 the death-rate was 34 per cent.; in 1886 
it was only 6 per cent. "Had they used any new remedy during the 
latter year the decrease in the mortality would undoubtedly have been 
ascribed to the new treatment." 

Ewing finds that "the antitoxin caused a diminution of the red 
blood-corpuscles and extensive changes in the leucocytes. These 
changes are likely to lead to obstructions in the capillary circulation, 
to changes in the kidneys, to necrotic foci in the liver, to pneumonia 
areas in the lungs, to obstructions of the cerebral circulation, and pos- 
sibly to convulsions/' 

Several deaths have been directly attributed to antitoxin injec- 
tions. One reported recently well illustrates these deplorable experi- 
ences. James L. Taylor writes to the Journal of the American Medical 
Association as follows: "A most unfortunate and distressing accident 
occurred in the practice of Dr. S. S. Halderman, of Portsmouth, Ohio, 
on March 22, in connection with the use of antitoxin. A mild form 
of diphtheria was prevailing in the family of Mr. George Kricker, 
cashier of the Central Savings-Bank, and the doctor administered 
the usual dose of antitoxin, as a prophylactic, to a little boy, 5 years 
old, in whom the disease had not yet appeared. The child, which 
had seemed to be in perfect health up to this time, was asleep when 
the injection was given, and in five minutes was a corpse. The doc- 
tor had withdrawn to another room to refill his syringe for use on 
another child when the mother noticed the boy's lips puffing up, and 
called to him that something was wrong with Willie. Bv the time 
the doctor had reached the child, breathing had ceased. The killing 



388 SERUM-THERAPY IN DIPHTHERIA. 

fluid, which thus acted with far more rapidity than a fatal dose of 
morphia, arsenic, or strychnia, given per mouth would have done, 
seems to have caused death by paralyzing the heart, At least, that is 
the cause assigned in the death-certificate. The serum was Behring's, 
fresh, injected beneath the scapula and in the usual way. The doctor, 
one of the first to introduce antitoxin into medical practice in Ports- 
mouth, was an enthusiastic advocate of serum-therapy, and presuma- 
bly used all the precautions which skill and experience can suggest. 
This terrible accident, therefore, can have but one meaning. It 
furnishes absolute proof of the inherent danger of antitoxin as a 
therapeutic agent." 

In a private letter of July 9, 1896, from Edwin Klebs, formerly 
of Germany, now Profesor of Pathology in the Chicago Post-graduate 
Medical School, he says: "The good effect (of serum-therapy) in the 
first two days of diphtheria seems to be doubtless." Eeferring to the 
Atlanta meeting of the American Medical Association, he continues: 
"I remarked the dangerous effects in some rare cases, as that of Pro- 
fessor Langerhans. Now the papers bring the notice that the death 
occurred by the introduction of stomach-contents in the bronchi. I 
do not know if that is acceptable, possibly post-mortal. I wished to 
point out the problem to get the antitoxin substances in a purer form, 
so that all possibility of infection may be avoided." In his discussion 
at the meeting referred to, Professor Klebs said: "Now I come to a 
point that seems to me to be of the highest importance,-^the danger 
of antitoxin. I wish that point would be illustrated in a more ex- 
tensive manner by publishing all cases in which the injection was 
shortly folloAved by death. We have such cases, but a part* of them 
seems to be on account of the disease. But if in one case alone the pa- 
tient has been killed by antitoxin, we have a great interest to find out 
the true cause of the death. Such a case is that of Professor Langer- 
hans, in Berlin. After a girl in the house became diphtheric, he 
thought he would, if possible, prevent the spreading of the disease to 
his own children; but after the injection the first child died imme- 
diately. So it is possible that death may occur after the most cautious 
injection of antitoxin, — a fact that gives a high responsibility to every 
physician using this remedy. We must search, therefore, to find out 
what may have been the cause of such fatal accident. 

"In this case it is reported that the body of the dead child was 
quite normal, well nourished. There was no introduction of air into 
the blood. The danger of introducing air is, by the way, not so great 



SERUM-THERAPY IN DIPHTHERIA. 389 

as often accepted. One can inject some centimetres of air in the 
blood-vessels of a rabbit without any bad effect, as the air is resorbed 
in a very short time. It will be better to inject the fluid in children 
into the muscles far distant from the lungs, — the dorsal or gluteal 
region. Then it is convenient to push the needle alone in first and 
see if bleeding follows or not. If not, one may inject without fear, 
but always slowly, under no high pressure. If these precautions are 
followed, I think that no danger can be feared from the injection. 

"I think it is not probable that the antitoxic serum itself con- 
tains such a formidable heart-poison, as very great quantities of it 
injected into the peritoneal cavity of animals prove harmless. Much 
more probable it seems to me, that in this and other similar cases 
observed in Brooklyn, !N\ Y., an accidental pollution of the antitoxin 
has combined with intravenous injection to produce fatal effect. 

"The sure disinfection of serum is a very difficult matter. Twice 
I have found microbes in tubercle serum. On the other side, the best 
antiseptics — as mercury bichloride, phenol, and kresol — make coagu- 
lations in the serum. Therefore, one must search for other disin- 
fectants that will not coagulate albuminous matters. I note that 
chinosol is proclaimed as such by Emmerich; its antiseptic action is 
forty times stronger than carbolic acid and it does not coagulate 
albumin. I have proved it a very good disinfectant for external and 
internal use, and I would recommend it for the disinfection of serum. 
Certainly we must demand from the manufacturers of antitoxic serum 
that they must prepare the serum in an absolutely-pure manner, ex- 
cluding totally the possibility of accidental pollution. It is not a 
good manner to dispense it in colored bottles. It can be protected 
against the light by dark coverings. 

"I am sure that all these precautions can be executed and will be 
executed in this land, in which I have seen as good bacteriologic work 
as anywhere in Europe." 

In another letter, dated December 1, 1897, Professor Klebs writes, 
among other things: "'My opinion is that we must have the antitoxins 
from the cultures and that we need not use more serum." He refers 
to a paper which he read at the meeting of the American Medical 
Association in 1897, in which he states that "In the serum there must 
be contained not only antitoxic, but also bactericidal, principles. It 
is, therefore, most probable that not only antitoxic, but also bacteri- 
cidal, principles work together to produce the curative effect of the 
serum. Furthermore, these bodies are not new products formed in 



390 SERUM-THERAPY IN DIPHTHERIA. 

the immunized animal, but transformed from the injected culture- 
fluid. This leads to the possibility that we are able to transform the 
culture as such directly, without the passage through the body of an 
animal, and my experiments in this line seem to emphasize this 
theory." 

In the case of the sudden death of Professor Langerhans's child, 
the official report says "that previous to the fatal injection the child 
had taken dinner, followed shortly afterward by some milk and cake. 
Death took place during a severe fit of coughing, and the necropsy 
showed that the trachea and bronchi were entirely filled with a gray 
substance, which was proved by microscopic examination to consist of 
particles of food, a good deal of the same being still present in the 
stomach. The uvula was swollen. The medical experts declare, there- 
fore, that the child died from suffocation. They are of the opinion 
that the boy vomited after the injection, and that, being in a fainting 
state from the pain of the injection, he was not able to get rid of the 
vomited matter, but drew it into the larynx in the act of inspiration. 
They did not find any embolus of air in the pulmonary artery, as was 
suggested, nor was there any confirmation of the opinion that death 
had occurred by syncope. According to the statement of the Control 
Office, the serum was of normal quality." (Journal of the American 
Medical Association.) 

Eeports of health commissioners of various cities give the results 
of the serum-therapy as follow: In New York City the death-rate 
was reduced by antitoxin from an average of 33.93 to 21.16 per cent.; 
Indianapolis, from 26.29 to 13.36 per cent.; St. Louis, in 1894, with 
no antitoxin, the death-rate was 28.2 per cent.; in 1895 the death- 
rate among those treated with antitoxin was 8.4 per cent. The 
Chicago Health Department reported in May, 1896, a reduction from 
52 to 9 per cent.; Boston, from 50 to 16. The Kaiser and Kaiserin 
Hospital, of Berlin, reports a reduction from 50 to 10 per cent., and 
the Willard Parker Hospital shows a mortality of only 10 per cent, 
under serum-therapy {Neiv Yor~k Medical Journal). In the Boston 
City Hospital the reduction in the death-rate was from 42 to 17 per 
cent. In the Johns Hopkins Hospital Bulletin W. H. Welch shows 
that, in 814 cases in which the serum was used before the third day, 
the percentage of deaths was only 5.5 per cent. 

Arthur K. Eeynolds, Commissioner of Health of the City of 
Chicago, writes to me under date of November 13, 1897, as follows: — - 

"Answering your queries concerning the antitoxin treatment of 



SEROI-THERAPY IX DIPHTHERIA. 



391 



diphtheria by the Chicago Department of Health, I submit the fol- 
lowing : — 

"1. Since October 5, 1895, when this treatment was begun by 
the department, and up to the close of last month, October 31, 1897, 
a total of 1658 cases of alleged diphtheria, were reported to the de- 
partment for investigation and treatment. Of this number 3982 cases 
were bacterially verified as true diphtheria, and in 3759 cases the 
antitoxin was permitted to be used, with the following results: — 

Total cases treated 3759 

Total cases recovered 3514 

Total cases died 245 

Death-rate, 6.51 per cent. 

"Among those treated subsequently to March 31, 1896 — records 
of intubations prior to that date are imperfect — there were 145 in- 
tubations, with 121 recoveries and 24 deaths. Death-rate of in- 
tubated cases, 16.53 per cent. 

""There were also treated with immunizing doses of antitoxin 
2631 cases of persons exposed in infected families, of which number 
16 were subsequently attacked with the disease, but all recovered. 

"As bearing upon the question of treatment with relation to age 
of patient and reported day of disease when first antitoxinized, the 
following are the figures of 1391 cases treated during the last twelve 
months, November 1, 1896, to October 31, 1897:— 

Kesults of Axtitoxix Teeatmext ix' Bacteeially-Veeified Diphtheeia. 



Day of Disease 

vhex First 

Treated. 


Totals. 


BY AGES. 


Recovered, by , 


^GES. 


Died, By Ages. 




Under 
1 year. 


1 too 
years. 


5 to 10 
years. 


Over 
10 yrs. 


Under 

1 year. 


1 to .5 5 to In 
years, years. 


Over 

In VIS. 


Under 
1 year. 


1 to 5 
years. 


5 to 10 
years. 


Over 
10 yrs 


First day . . . 


26 


76 


54 


33 


26 


75 54 


33 





1 








Second day . 


45 


155 


112 


71 


41 j 153 110 


71 


4 


2 


2 





Third day . . . 


32 


168 


120 


77 


31 157 113 


73 


1 


11 


7 


4 


Fourth day . . 


32 


97 


60 


45 


30 


89 


58 


42 


2 


8 


2 


3 


Later than 
fourth day 


20 


74 


61 


33 


11 


57 


50 


25 


9 


17 


11 


8 


Totals 


155 


570 


407 


259 


139 


531 


385 


244 


16 


39 


22 


15 



392 SEBUM-THERAPY IN DIPHTHERIA. 

"There were 92 deaths in the 1391 cases treated: a mortality- 
rate of 6.61 per cent. 

"With reference to reported day of disease when first treated, 
there were 189 treated on the first day, with 1 death: mortality-rate, 
0.53 per cent.; 383 on second day, with 8 deaths: mortality-rate, 
2.06 per cent.; 397 on third clay, with 23 deaths: mortality-rate, 
5.79 per cent.; 234 on fourth day, with 15 deaths: mortality-rate, 
6.41 per cent.; and 188 first treated later than the fourth day of the 
disease, with 45 deaths: a mortality-rate of 23.92 per cent."' 

Since Eeynolds introduced the use of antitoxin in the Health 
Department of Chicago in 1895 the productions of Behring; Roux; 
Parke, Davis and Company; Mulford, and others have been employed. 
Four grades are now used, as follow: — ■ 

Grade No. 3A. — Vials contain 5 cubic centimetres, 150 anti- 
toxin units (Behring's standard) to each cubic centimetre, or 750 
units. 

Grade No. 4. — Vials contain 5 cubic centimetres, 200 antitoxin 
units (Behring's standard) to each cubic centimetre, or 1000 units. 

Grade No. 5. — Vials contain 5 cubic centimetres, 300 antitoxin 
units (Behring's standard) to each cubic centimetre, or 1500 units. 

Grade No. 6. — Vials contain 5 cubic centimetres, 400 antitoxin 
units (Behring's standard) to each cubic centimetre, or 2000 units. 

The department has issued a circular of information, which con- 
tains such important advice, of practical value, that wa. will quote 
briefly from it: "It is apparent that preparations of antitoxic serum 
which contain a large amount of antitoxin to each cubic centimetre 
are more desirable than those containing a smaller amount, since the 
dose required is proportionately less, and disagreeable symptoms, 
which sometimes follow injections of the larger quantity of the weaker 
serums, will be avoided. The highest-grade preparations, however, 
are much more difficult to produce, are necessarily more expensive, and 
at present, even with approved (improved?) methods, can be produced 
only in limited quantities. 

"The average curative dose of diphtheria antitoxin is about one 
thousand (1000) units; but for very severe cases, or croup cases, or 
those in which the serum is not administered until the third day or 
later, fifteen hundred (1500) or two thousand (2000) units are often 
required, and sometimes the dose must be repeated; so that altogether 
from four to six thousand units may be required in a single case. Full 
directions as to the use of the serum accompany each vial. 



SEBini-THEBAPY IN DIPHTHEBIA. 393 

"From one hundred (100) to three hundred (300) units, according 
to age, are required to confer immunity. The immunity thus pro- 
duced ordinarily lasts for a period of at least four weeks. With the 
new and strongest preparations of antitoxic serum, only very small 
quantities of the serum. (from 6 to 15 minims) are necessary for the 
production of immunity.*' 

To those who are interested in the subject of diphtheria — and 
who can be otherwise, considering its intensely-interesting character, 
and its supreme importance to every practitioner of medicine? — a few 
of the common, but startling, experiences of the antitoxin staff of 
the Chicago Health Department will serve a useful purpose. The fol- 
lowing notes are from the daily register of E. P. Murdoch: "At the 
request of a physician I attended a funeral of a child known to have 
died from malignant diphtheria. Services in the chapel; over two 
hundred persons present, eight little girls acting as pall-bearers. 
Twenty others marched in procession from the house to the chapel 
where the corpse was carried by the children; all passed around the 
open coffin and viewed the remains and many kissed the corpse. I 
secured the names and addresses of fifteen children present, and 
traced nine cases of diphtheria to this source, with four deaths. Eec- 
ommended funeral inspection. 

"Was called into the Seventeenth Ward to treat a case of diph- 
theria. Found seven people living in two small rooms, three children 
sick with diphtheria in one bed; one died while I was there. On 
that same bed were two large bunches of bananas, still green, but 
ripening for the purpose of being peddled upon the streets to un- 
suspecting people. 

"Was called in the night to see a family in a basement on Austin 
Avenue. Five children sick; one dead; nine visitors present, some 
of whom were women with their nursing babies in their arms. To this 
one source I traced thirteen cases of diphtheria, with five deaths/* 

One of the inspectors, Frank X. Walls, related that he was called 
to administer antitoxin to a child 4 years old, but on his arrival the 
mother concluded that the child was so much better that the treat- 
ment would not be required. While discussing the importance of 
protecting the other members of the family from infection the child 
suddenly screamed, fainted, and died. If the antitoxin had been ad- 
ministered, probably the sudden death would have been attributed 
to the remedy, instead of to the disease. 

Another inspector, M. M. Eitter, visited a family in which three 



394 'SERUM-THERAPY IN DIPHTHERIA. 

children were suffering from diphtheria. He was about to administer 
antitoxin to all of them, but, while he was treating one of the chil- 
dren, the smallest one who had first been attacked by the disease sud- 
denly sank into the mother's arms and died. 

Commenting on these sudden deaths, Murdock says: "On two 
occasions when the injections of 10 cubic centimetres were given in 
too great haste, without previously preparing the patient for the op- 
eration, I have witnessed alarming syncope, but in both cases the pa- 
tients were revived, and made a good recovery, thus warning me that 
careless or unskillful hands may produce serious or even fatal results, 
and thereby convey the idea that the remedy was the cause." 

The Health Department reports that no serious symptoms have 
resulted from the antitoxin itself: "There has been some local pain 
at the seat of the injection (just above the crest of the ilium), some 
swelling and redness, urticaria following from three to ten days after 
its use, but in no case were the sequels one-half so painful or so 
formidable as the mildest sequences of successful vaccination. There 
have been a few cases of albuminuria a few days after the use of 
immunizing doses of antitoxin, but these have been very transitory 
and soon pass away, with complete recovery — never any serious con- 
sequences; while, in all cases of marked albuminuria resulting from 
diphtheria, the renal symptoms rapidly subside after the administra- 
tion of antitoxin of the proper strength and quantity. Albuminuria 
from antitoxin has not been observed since we have been, using the 
higher powers of antitoxin with smaller amounts of serum. Not only 
that, but careful experimentation has convinced us that albuminuria 
came from the large use of the serum and not from the antitoxin 
itself, and the same may be said of other sequels. The effect upon the 
diphtheric infection is most remarkable: at once arresting the disease 
if used in the early stages and properly administered, and giving ex- 
cellent results even when used after the fourth day, although this 
cannot be so confidently expected as when the antitoxin is used early." 

Eegarding the status of medical opinion, an editorial in G-aillard's 
Medical Journal says: "The present status of the question undoubt- 
edly justifies the early use in moderate quantities of a good prepara- 
tion of antitoxin. We are not prepared to say the failure to use it 
under such conditions would be as easy to explain or to justify. The 
records of the last eighteen months have shown, throughout the whole 
civilized world, such a material decrease in the percentage of deaths 
from diphtheria where antitoxin has been used that the evidence of 



OPINIONS AXD PEACTICE OF CHICAGO PHYSICIANS. 395 

its value cannot be neglected, however much it may be questioned. 
Only last week one of the best-known practitioners in New York City, 
who has given special attention to this subject, both in this country 
and abroad, made a most bitter attack upon antitoxin as a therapeutic 
agent, the same writer having taken the same stand early in the days 
of antitoxin therapeusis. There were several others at this meeting 
who gave their support to the speakers views, and the question there- 
fore becomes again one for earnest consideration and discussion." 

J. M. French, in reviewing the first year of the antitoxin treat- 
ment, maintains that the harmless character of the serum has been 
demonstrated in more than 100,000 injections. 

"Taking all cases reported together, the practical result of the 
first year's use of antitoxin, so far as can be judged at the present 
time, has been to lessen the death-rate from diphtheria, in cases where 
it has been used, nearly or quite one-half, thus proving itself beyond 
all doubt to be the most successful of any known treatment for this 
dread disease. It is confidently predicted that the results will be 
even more favorable the second year, owing to improvements in the 
methods of preparing, preserving, and administering the serum. 
There is also every reason to anticipate that the same success which 
now attends the treatment of diphtheria by the serum method will 
soon be attained in the cases of a number of other specific diseases." 
(Medical and Surgical Reporter.) 

The use of antitoxin in the Cook County Hospital, Chicago, was 
begun in July, 1895, and was continued under the charge of D. D. 
Bishop, AY. L. Baum, and A. C. Cotton. The results were published 
by H. A. Brenneeke, who says: "According to the various statistics, 
the mortality of diphtheria before the use of the serum is placed at 
about 40 per cent. Since the serum has been used in the Cook County 
Hospital the mortality, as is shown by the tables, has been reduced to 
12.5 per cent. (Medicine, January, 1898.) 

The opinions and practice of Chicago general physicians are fairly 
represented by the following extracts from communications to the 
editor of the North American Practitioner, J. H. Hollister, and pub- 
lished in April, 1896:— 

H. M. Lyman: "I have seen no cases of diphtheria since the introduction 
of the antitoxin treatment of the disease, but, whatever may be concluded re- 
garding the antitoxin treatment, there are certain measures that should never 
be neglected in the management of diphtheria: 1. The maintenance of general 
and local cleanliness by means of gargles, injections, vapors, and sprays, so far 



396 OPINIONS AND PRACTICE OF CHICAGO PHYSICIANS. 

as they can be used without risk of exhausting the patient, or terrifying him 
if a young child. 2. The sustentation of strength by the frequent administra- 
tion of milk, broth, eggs, and alcohol. 3. The encouragement of renal and 
intestinal elimination by the use of mercurials in small and frequent doses. 4. 
The avoidance of all drugs that are disagreeable and irritating, such as the 
tincture of the sesquichloride of iron, quinine, etc. 

"During the period of convalescence, especially if the patient has passed 
the period of infancy and early childhood, the treatment may be conducted 
in accordance with general principles. The occurrence of paralysis calls for 
special treatment of the neural inflammation by which it is caused." 

Wm. E. Quine: "Local Treatment. — None except poultices, which are 
recommended when there is much swelling of the lymphatics. I disapprove 
strongly of the use of the brush and probang, and have come to regard the 
atomizer with indifference. 

"Internal. — In ordinary pharyngeal diphtheria my routine treatment con- 
sists of the administration of the tincture of iron, — 1 drachm in an ounce of 
a mixture of glycerin and syrup. Of this a teaspoonful is given for a dose, 
and never less than half a teaspoonful, even to an infant, every two hours or 
every hour, according to the severity of the case. The medicine is given un- 
diluted, and no drink is permitted immediately after it. The object is to have 
it adhere to the affected parts. In case vomiting occurs, Vs or 1 / i minim of 
carbolic acid is added to each dose; and if vomiting persist, which is rarely 
the case, the treatment is stoutly maintained, nevertheless. Corrosive subli- 
mate, chlorate of potassium, whisky, and quinine are not, in my opinion, im- 
portant additions to the treatment. Laxatiyes are given as required. Recum- 
bency is enjoined. Feeding is attended to with urgent insistence. 

"Antitoxin. — My experience has been limited for the most part, but not 
entirely, to its use in cases of nasal and laryngeal involvement. In such cases 
I employ it at once, — Behring's, or that of the New York Board of Health, 
or of the Pasteur Laboratory, or of Park, Davis & Company. I have not wit- 
nessed a failure, and have not seen any harmful result beyond the appearance 
of a transitory eruption on the skin in a few cases, and the occurrence of 
transitory albuminuria in a like manner; but, nevertheless, my respect for 
the observations of others, recorded and unrecorded, in relation to untoward 
events Avhich must be ascribed directly to the influence of the antitoxin, holds 
me to a preference for the iron mixture in cases of uncomplicated pharyngeal 
diphtheria." 

(During the winter of 1897 and 1898 Dr. Quine modified the foregoing 
remarks by the addition of the following statement: "Additional experience 
has strengthened my confidence in the antitoxin treatment as being the best 
and safest known to the medical profession. The immediate employment of 
the antitoxin is an essential prerequisite to the most successful operation. I 
have had occasion more than once to regret my own slowness of action.") 

"Formerly I regarded the atomizer as an important aid to treatment, 
especially of diphtheria of the larynx, and antiseptic injections, such as a weak 
sublimate solution, repeated every two or four hours, as indispensable to the 
efficient treatment of nasal diphtheria; but for the past year or so I have been 
falling away from these measures and relying on the antitoxin." 



OPINIONS AND PRACTICE OF CHICAGO PHYSICIANS. 397 

J. A. Robisox: "Prior to the introduction of the antitoxin treatment it 
was truly said: 'there is no specific treatment for diphtheria.' But my experi- 
ence recently in the use of antitoxin in five cases of true diphtheria has con- 
verted me to the belief that it is a specific. Antitoxin, in my opinion, is the 
prince of remedies. Yet there are cases in which I would not cease to employ 
the older methods of treatment." 

Feaxk Billings: "General Treatment. — The temperature of the patient 
to be controlled by frequent bathing with water. The boM'els should be freely 
evacuated in the first twenty-four hours by the use of calomel combined with 
sodium bicarbonate, in doses graded to the age of the patient. Strychnia sul- 
phate, in doses graded to suit the age of the patient, from the beginning to 
the end of the disease, as a general and as a cardiac tonic. Alcohol, in the 
form of sherry-wine, whisky, brandy, or rum to be used only in cases of great 
toxaemia, in frequently-repeated small doses, when used at all. In the great 
majority of cases it is not necessary, and I think it should be reserved as a 
final antitoxin. A diet fluid in form of milk, milk and egg, animal broths, 
gruels, koumiss, inatzoon, or any modified milk. 

"Local Treatment. — The following plan gives me great satisfaction: A 
thorough cleansing of the pharynx and naso-pharynx with a solution of H 2 2 : 
for the pharynx diluted two or three times, for the nose and naso-pharynx five 
or six times; by having the patient gargle or by spraying the pharynx, and 
by syringing the naso-pharynx through the nose. I believe in applying treat- 
ment through the nose as well as upon the pharynx in all forms of throat 
diphtheria. After cleansing with H 2 2 I use 

F£ Hydrarg. chlorid. corrosivi, . . . gr. Vioo to Vso- 

Sacchari albi, gr. iii to v. 

Mi see; triturate. 

Ft. chart, no. j. 

Signa : Apply dry upon the tongue every hour. 

"This does very well with all patients, and with children is taken readily ; 
it is applied directly to the pharynx and is also an efficient constitutional 
remedy and laxative. It is to be withdrawn if diarrhoea or bloody-mucous 
stools occur. 

"To the nose, after cleansing, apply with a syringe a solution of corrosive 
sublimate in water, 1 to 10,000, every two hours. 

"A steam-spray should be kept playing almost constantly over the head 
of the patient. 

I£ Acidi carbolici, . 3j. 

Zinci sulphocarbolatis, 3j. 

Glycerini, 5j- 

Aquas, q. s. ad §iv. 

Misce. Signa: To be used in the steam-spray atomizer; or 

F£ Glycerini, gj. 

Aquae calcis, giij. 

Misce. Signa: Use in the steam-atomizer. 



398 OPINIONS AND PEACTICE OF CHICAGO PHYSICIANS. 

"These solutions remain suspended in the air quite a time, and seem to 
afford the patient much relief. 

"In ease corrosive sublimate cannot be borne, I consider tr. ferri chloridi, 
3ij; glycerini, Sj; aquse, §iij, may be used in place of it; 3j every hour. 

"I consider antitoxin of great benefit in all cases, — greatest when used 
early in the disease. A maximum dose should be used in all cases and should 
be repeated within twelve hours. I would not hesitate to use it in a case, no 
matter what the complication. I believe, however, in carrying out a thor- 
oughly-planned local and general treatment, even when the antitoxin is used." 

A critical review of the great mass of evidence accumulated, both 
favorable and unfavorable, to the blood-serum therapy, a small frac- 
tion of which is here presented, forces the conclusion that the pre- 
ponderance of evidence justifies the verdict that diphtheria antitoxin, 
administered early and in sufficient doses, — the first or second or not 
later than the third clay of the disease, has the power to prevent a 
fatal issue. Given later it may modify the intensity of the toxaemia 
if a multiple of the ordinary dose be given. 

Mixed infection, and invasion of the larynx demanding intuba- 
tion or tracheotomy, lessen the chances of recovery. 

While the serum is a powerful remedy and may be capable of 
doing harm, the disease itself is so virulent that, in view of the great 
weight of testimony and statistics in favor of the antitoxin, the phy- 
sician should not fail to avail himself of this addition to thorough 
local and general treatment. 



CHAPTEE XXXIII. 
DISEASES OF THE PHARYXX, CONTINUED. 

Tonsillitis. 

Uxdee this heading it is convenient to treat of acute inflamma- 
tion of the tonsil and of the peritonsillar tissue. 

Synonyms. — Quinsy; amygdalitis; phlegmonous sore throat: 
angina tonsillaris; ulcerative tonsillitis; suppurative tonsillitis; ab- 
scess of the tonsil. 

Pathology. — This is an acute inflammation of one or both tonsils. 
There are three principal varieties: (1) simple catarrh, (2) ulcerative 
tonsillitis, and (3) abscess of the tonsil. 

Some authorities distinguish five varieties of this disease, but 
practically they are all variations of three types of inflammation. 
The inflammatory action may be of a mild catarrhal character and 
limited to the mucous membrane, or it may eventuate in superficial 
ulceration, or it extends to the submucous tissues, with infiltration 
of the whole gland and the peritonsillar connective tissue. In the 
second and third forms the lacunae, or crypts that indent the surface 
of the tonsil, are filled with micrococci, pus, and epithelium. 

Tonsillitis is most frequent in persons between the ages of 15 and 
30 years, and especially among those of a rheumatic habit and with 
hypertrophied tonsils. The inflammation usually involves to a greater 
or less degree the pillars of the fauces and uvula. They are red and 
swollen and the uvula elongated and troublesome (Plate IV). The 
attack may terminate in resolution, ulceration, abscess, or hypertro- 
phy. In the case of an abscess it may rupture near the superior and 
anterior portion of the tonsil in the vicinity of the arch of the soft 
palate. The orifices of the crypts may become obstructed, with the 
result of distending these cavities with the pent-up secretions. 

With regard to the bacteriology of tonsillitis, it cannot be said, 
at the present time, that the various forms of tonsillitis are caused by 
any special organism, although they may be traced to a microbic in- 
fection. A. Yeillon (Archives de Medecine, March, 1894) concludes 
that "pathogenic microbes may be found in all forms of non-diph- 

(399) 



400 TONSILLITIS. 

therm tonsillitis. The streptococcus pyogenes virulens was present 
in the twenty-four cases examined, and was usually associated with the 
less virulent pneumococci and sometimes with staphylococci. The 
streptococcus appears to play the most important role in all cases. 
The different kinds of tonsillitis are of the same nature. The clinical 
and anatomical differences depend upon (1) whether the organisms 
affect the surface of the mucous membrane, its deeper layers, or the 
subjacent cellular tissue, and (2) the virulence of the microbes and 
the resistance of the subject." 

Etiology. — While tonsillitis is not usually met with in persons 
younger than 15 or older than 30 years, I have seen it above the 
fiftieth year. No age is absolutely exempt. In my opinion, rheuma- 
tism is an important factor in the production of this disease. A close 
relationship is often observable between attacks of tonsillitis and rheu- 
matism, one following or preceding the other — one subsiding as the 
other develops. Cold, damp, foggy, or changeable weather is a pre- 
disposing cause; the presence of hypertrophy and the history of pre- 
vious attacks presage future ones. Unusual exposure is a frequent 
excitant of this as it is of other inflammations. The crypts are often 
found filled with caseous masses that excite inflammatory action. 
These cheesy plugs undergo decomposition and become acrid, irri- 
tating, and foul-smelling. Acute tonsillitis occasionally follows nasal 
cauterization. 

Symptomatology. — Premonitory symptoms are: a heavy feeling 
akin to exhaustion, followed by a sense of feverishness, headache, and : 
pain in the back and legs. Chilliness may be present during the first 
few hours and the temperature may rise to 103° or 105° F. by the 
second day. If the fever is very high it indicates that the deeper 
structures are likely to become the seat of an abscess. As the disease 
progresses, the tonsil becomes swollen and obstructive to deglutition;, 
sensations as if a foreign body were in the throat, together with in- 
creased secretion of mucus, occasion frequent efforts to free the throat 
by swallowing, which becomes more and more difficult. All the sur- 
rounding tissues may participate in the inflammation in the severe 
type so that the velum and uvula are red, thickened, and sensitive. 
The elongation of the uvula to the extent of constant contact with: 
the tongue (Plate IY) adds to the excitants of painful deglutition. 
When the inflammatory action extends to the orifices of the Eusta- 
chian tubes and to the pharyngeal tonsil, impaired hearing, noises, 
and even pain in the ears ensue. These symptoms represent the crisis- 



TONSILLITIS. 401 

of the simple catarrhal form of a severe character, and now begins an 
abatement of the inflammation, subsidence of the pain, swelling, diffi- 
cult swallowing, and the membrane begins to assume a more natural 
color. 

In the second, or ulcerative, form, instead of an amelioration of 
all the symptoms at the crisis of the inflammation, the mucous mem- 
brane softens and breaks down in spots. The surface of the gland is 
dotted with small, yellowish-gray points (Plate IV) that coalesce and 
form irregular ulcers covered with a muco-purulent discharge. I 
have known physicians to mistake this coating of the ulcers for a 
diphtheric exudate, but the deposit can be seen at first as limited to 
the orifices of the lacuna?, and there is a wide difference between the 
two, even in macroscopic appearances. 

When the inflammation extends to the deeper structures speech 
is seriously interfered with, and it is difficult to articulate with suffi- 
cient clearness to be understood. The mouth cannot be opened on 
account of the pain and tumefaction about the angle of the jaw, and it 
may be well-nigh impossible to examine the pharynx, even with the 
aid of the forehead-mirror and tongue-depressor (Plate IV). In this 
stage cold sweats and sleeplessness are sometimes experienced. 
Liquids regurgitate into the nose or find their way into the larynx, 
occasioning most violent fits of coughing and strangling. The cervi- 
cal muscles sometimes become sore and tender on pressure. The con- 
tinuous exertions necessary to clear the throat of secretions, which 
are not swallowed, but allowed to slaver from the mouth, serve to in- 
crease the distress. When the uvula can be seen, it is found clinging 
to the affected tonsil. While the secretion of saliva is increased, the 
urine is diminished in quantity and of high color. The breath be- 
comes freighted with a fetid odor and the tongue is furred with a yel- 
lowish-gray coat. The bowels are generally constipated. 

Mild attacks of tonsillitis may not extend beyond a week, but the 
severe form, which terminates in an abscess, is a tedious type. In 
the course of a week or ten days a chill denotes the formation of pus, 
and a little later, if the abscess is not opened, it breaks, usually in the 
throat. However, it may rupture externally at the angle of the jaw, 
or burrow underneath the cervical muscles, forming an abscess of the 
neck, or it may gravitate to the thoracic cavity. 

Diagnosis.— The characteristic symptoms described render a diag- 
nosis comparatively easy. There is not much likelihood of confound- 
ing this disease with any other except diphtheria. In the latter disease 



402 TKEATMENT OF TONSILLITIS. 

the tonsils are not always swollen, and the false membrane is thick, 
leathery, and of much lighter color generally. Yet it must not be for- 
gotten that the Klebs-Lofner bacillus is sometimes found in the throat 
when there is no false membrane; so that in suspicious cases a bac- 
teriological examination should be made. In the sore throat of 
measles and scarlet fever the distinguishing rash, the ease of opening 
the mouth, and the comparatively little enlargement of the tonsils 
clear up any doubt. Syphilitic sore throat does not present the in- 
tense group of symptoms of severe tonsillitis, and can be differentiated 
from the mild catarrhal form, in that fever and pain are generally 
absent and the difficulty of swallowing is not so prominent a symp- 
tom. Patches of redness, instead of the bright, diffused, red glow of 
acute tonsillitis, characterize the early stages of syphilis, while the 
secondary stage is manifest in the mucous patches and skin eruptions, 
and the tertiary stage in the deep ulcerations and an unmistakable 
history. 

Prognosis. — Simple catarrhal tonsillitis usually terminates in 
resolution, running a course of about a week. It is often preceded or 
followed by a rheumatic attack of other structures, and may end in 
tonsillar hypertrophy. Ulcerative tonsillitis also tends toward re- 
covery, but the possibility of invasion of other parts, such as the Eusta- 
chian tubes and tympanic cavities, emphasizes the necessity for effi- 
cient treatment. Occasional deaths have occurred from tonsillar ab- 
scess breaking into the larynx or causing laryngeal oedema. The 
occurrence of an abscess lengthens the attack to two or three weeks 
and sometimes longer. 

Local Treatment. — Local applications of glycerin of tannin have 
proven effective in the simple catarrhal tonsillitis. I am aware of the 
opposition to this treatment by high authority (Lennox Browne), 
but one cannot ignore years of actual satisfactory experience with it. 
The writer has made it a practice to apply this remedy with a very 
soft, bushy earners hair pencil every two or four hours. If there is 
considerable pain, a 10-per-cent. solution of carbolic acid in glycerin 
will afford a local anesthetic effect, besides depleting the vessels and 
acting as an antiseptic. I have found local applications of guaiacol 
useful. It appears to shorten the attack. If the pure drug is painful, 
it can be diluted one-half with glycerin. Gargles of alum-water and 
potassium bromide in 4-per-cent. solutions are grateful in some cases. 
Much refreshing relief is experienced after copiously spraying the 
throat with benzoinated lavolin or a 3-per-cent: solution of camphor- 



TREATMENT OE TONSILLITIS. 403 

menthol (Figs. 129 and 130). The authors throat-tablets also have 
given excellent satisfaction. Each tablet contains the equivalents of 

I£ Ammonii chloiidi, . . . . . . gr. j. 

Tincturse opii camphoratae, 
Syrupi seillae composite 

Syrupi Tolutani, of each, min. v. 

Extracti glycyrrhizae, gr. iij. 

These are allowed to melt slowly in the mouth, so as to prolong 
the contact of the remedies as much as possible with the inflamed 
membrane. C. E. Bean recommends a compound rhatany lozenge, 
consisting of 2 grains of extract of rhatany, X / Q grain of extract of 
opium, and 18 grains of currant-paste. 

Ulcerative tonsillitis should be treated with alkaline disinfectant 
and antiseptic topical applications. Frequent sprays of hydrozone, 
DobelFs and Seiler's solutions, grycothymolin, listerin, pasteurin, 
borolyptol, etc., will cleanse and disinfect the glands, after which a 
covering of aristol should be given with the powder-blower (Fig. 34). 

If an abscess is threatened by the severity of the symptoms, local 
cold should be used early by means of an ice-bag (Fig. 83) directly 
over the tonsil. As soon as an abscess can be discerned it should be 
opened instead of waiting for nature to accomplish this. Several days 
of extreme wretchedness will be spared the sufferer by this means. 
The knife should have a handle sufficiently long to not hamper one 
in his movements. The cutting-edge must be kept toward the median 
line so as to avoid wounding the internal carotid artery, which might 
occur by a sudden movement of the patient if the cutting edge were 
directed toward the artery. The abscess usually points near the arch 
of the anterior faucial pillar. E. C. Myles injects a few drops of a 
4-per-cent. solution of cocaine into the tissues before incising them 
(The Laryngoscope, February, 1898). 

For phlegmonous tonsillitis Gouguenheim (Lyon Medical, 1894) 
recommends Leiter's coil around the throat, leeches to the angle of 
the jaw, 20- to 33-per-cent. cocaine painted in the pharynx, irriga- 
tions with warm boric-acid solution, and salol or naphthol internally 
for an intestinal antiseptic. 

Tonsils that are subject to recurring attacks of inflammation 
should be guillotined (see division on tonsillotomy). Kitchen excises 
the tonsil to abort an impending attack of quinsy, and to prevent 
future attacks. 



404 TREATMENT OF TONSILLITIS. 

Constitutional Treatment. — When the pain is severe and swallow- 
ing difficult, I have seen the most gratifying relief attend the admin- 
istration of a combination of morphia with atropia in the proportion 
of V 8 grain of morphia to 1 / 600 grain of atropia. This remedy relieves 
pain and irritability, checks the excessive secretions that constantly 
excite efforts to swallow, and modifies the intensity of the inflam- 
matory process. Patients to whom I have administered this for the 
first time, and who have been in the habit of passing through similar 
attacks for years, have remarked with unfeigned gratitude that they 
had never before received such relief from suffering during a siege of 
their malady. A laxative should be given at the onset of the attack, 
so as to open the bowels freely. Aconite enjoys, quite a reputation 
in this disease, given in closes of 2 or 3 drops every half -hour. Potas- 
sium bromide, mentioned in connection with local treatment, has a- 
beneficial sedative effect if some of it is swallowed after gargling with 
it, so that 10 grains every two or three hours are taken. 

The rheumatic character of this affection calls for such remedies 
as salicylic acid and antipyrin. If there is no reason why salicylate of 
sodium should not be given, it is to be preferred. When it is well 
borne the writer gives 10 grains every two hours until the symptoms 
become ameliorated or slight physiological effects are produced. A 
freshly-prepared solution should be used, for example, as follows: — 

I£ Aeidi salicylici, 3iij. 

Sodii bicarbonatis, 3ij. v 

Elixiris gaultherise, §ss. 

Glycerini, . . . . . .■■.". 3iij . 

Aquae, q. s. ad §iv. 

Misce. Signa: One teaspoonful, in water, every two hours. 

If salicylate of soda disagree with the stomach or cause ringing 
in the ears, salicin should be substituted in pilular form, 5 grains to 
be taken every two or four hours. 

Antipyrin in doses of 5 or 10 grains every three or four hours 
not only relieves pain, but possesses especial efficacy in rheumatic 
affections. 

Salophen and salol, given in effective doses early in an attack, 
will subdue the inflammation and apparently prevent the formation of 
an abscess. They should be administered in 5- or 10-grain doses every 
two to four hours, at first, according to the age of the patient and the 
severity of the attack. 



HYPEKTKOrHY OF THE TOXSILS. 405 



Hypertrophy of the Tonsils. 



Synonyms. — Enlarged tonsils; chronic tonsillitis; follicular ton- 
sillitis. 

Pathology. — Hypertrophy of the tonsils is a true hyperplasia, 
according to Virchow, in which all the glandular elements participate 
in the proliferous process. The increase and induration of the con- 
nective tissue is manifest in some tonsils at the time of excision, by 
the resistance to the passage of the guillotine through them, but in 
most instances they are yielding and sponge-like. The crypts are ex- 
panded and their walls are tumefied. Instead of a tenacious mucus 
filling the cavities there are often cheesy masses of a light-yellow color 
sometimes mixed with calcareous concretions. There is an increase 
in size and usually in number of the follicles surrounding the de- 
pressions, rforris AYolfenden {Journal of Laryngology, etc., August 
18, 1894) reports the results of studies in follicular tonsillitis as fol- 
low: "Follicular tonsillitis is a desquamative process in the crypts 
of the tonsils, the follicles taking no part in the process and only ex- 
hibiting a secondary hypertrophy, as recently maintained by Sokolow- 
ski and others. There are other forms of infective tonsillitis asso- 
ciated with the exudation of fibrin, the presence of streptococci, staph- 
ylococci, and pneuniococci." 

In the follicular, or lacunar, tonsillitis the pseudomembrane 
shows staphylococci and streptococci and the pseudodiphtheric ba- 
cillus. It cannot always be distinguished from diphtheria except by 
bacteriological examinations. 

Kriickmann (Yirchow ? s Archiv) confirms Hanau and other ob- 
servers in the view that the tonsils are the portal of entrance for 
tubercle bacilli in cases of tuberculosis of the cervical lymphatic 
glands. 

In this connection it is interesting to note that in the tissue of 
the floor of the mouth have been found the staphylococcus aureus, 
streptococcus, diplococcus, and certain bacilli, probably the bacillus 
septicus or the bacillus cedematis maligni of Koch and Pasteur. Prob- 
ably Ludwig's angina arises secondarily from a streptococcic infection 
of the glands, and affected teeth or bones may be an important etio- 
logical factor in both diseases. 

Etiology. — Hypertrophied tonsils are found in the very young so 
commonly that they may be spoken of as being congenital, but in 
many instances they develop about the age of puberty. The largest 
number of cases are seen between the ages of 10 and 20 years, the 



406 HYPERTROPHY OP THE TONSILS. 

next largest under the tenth year, and those occurring between 20 
and 30 years are next in frequency. After the thirtieth or fortieth 
year tonsillar hypertrophy is rather infrequent, for their growth ceases 
and the process of atrophy sets in about the thirty-fifth year. Nearly 
twice as many males are affected as females. 

The rheumatic habit; living in a damp, cold atmosphere; re- 
curring attacks of inflammation, the throat complications of the 
eruptive diseases, diphtheria, syphilis, and the strumous diathesis are 
all productive of those conditions that predispose to an increase in 
the volume of these glands. After the thirty-fifth year I do not advise 
the removal of the tonsils unless there is some special reason for it, 
since their gradual diminution in size and tendency to inflame dates 
from about this period of life. 

Symptomatology. — The features of a child with enlarged tonsils 
often present a picture which suggests at once the nature of the 
trouble. Previously to an examination of the throat one is often able 
to predict the condition to be found. The tinder-jaw drops, the mouth 
remains continuously open, the eyelids droop, and the face is ex- 
pressionless and suggestive of a dull intellect (Fig. 185). During 
sleep the respiration is noisy and of a snoring character. Associated 
with hypertrophied tonsils in a large proportion of children so af- 
fected will be found an enlargement of Luschka's tonsil, or adenoid 
vegetations in the vault of the pharynx. In these associated diseases 
with obstruction to the current of air through the nose by adenoids and 
the backward projection of the oral tonsils, and to the passage of air 
through the mouth by the blocking up of the fauces with the oral 
tonsils, the ox}^genation of the blood is seriously interfered with. 
The effects on the voice are readily apparent. The resonance of the 
nasal cavities is so diminished that speech has a thick, unnatural nasal 
quality, and the articulation of words is impeded and difficult (Plate 

ii). 

The tonsils are situated in such close relationship to the Eusta- 
chian orifices that any disease of these glands threatens impairment 
of the integrity of the Eustachian tubes and middle ears. While the 
tonsils are not so situated as to produce actual pressure upon the 
tube-mouths, as was formerly supposed, any inflammatory action af- 
fecting the gland readily extends by continuity to the tubal mem- 
brane. The large number of patients with hypertrophied tonsils who 
suffer from middle-ear diseases is suggestively significant. Mackenzie 
and others speak of defective smell and taste in tonsillar hypertro- 
phies. 



TREATMENT OF HYPERTROPHY OF THE TONSILS. 4:07 

Great embarrassment of the respiration may interfere seriously 
with the general health, and in very young persons, or those with a 
tendency to rickets, the chest-walls may become deformed, resulting 
in pigeon-breast, or a pyriform deformity. 

Inspection of the throat reveals the tonsils tumefied (Plate IV) 
and in some instances so enormously enlarged as to lie in contact with 
each other and to cut off a view of the posterior wall of the pharynx. 
They are generally very red, soft, and yielding, and can be crowded 
through the fenestra of a tonsillotome so small that it would seem 
impossible. 

Diagnosis. — A view of the pharynx under good illumination is 
sufficient to establish the diagnosis. There is a possibility of mis- 
taking an enlarged tonsil for a pharyngeal abscess, but the chances 
are remote. The location of the tonsil and. if necessary, palpation 
with one finger on the tonsil and another over its base under the angle 
of the jaw. would distinguish the location and character of the tumor 
(Plate V). 

Prognosis. — Probably the vast majority of hypertrophied tonsils 
are never removed or even treated, yet it is the exception to find them 
after the thirtieth or fortieth year. This means that there is a 
natural reduction to the normal size after adolescence or middle life. 
However, there are many individuals with impaired hearing that is 
attributable either directly or indirectly to the presence of tonsils that 
have been subject to repeated attacks of inflammation. In adult life 
I rarely advise their removal unless they are provocative of some dis- 
turbance, for in many they occasion no inconvenience. But I have 
seen persons in middle life who were subject to so much suffering 
from attacks of quinsy that they sought relief by excision. It must 
not be forgotten that the lacuna? of the tonsils, from twelve to eight- 
een in number for each gland, afford nests for the reception and cult- 
ure of micrococci that may give rise to more serious trouble. These 
depressions are sometimes very deep, plunging down into the paren- 
chyma of the gland, and form an ideal incubator for the development 
of micro-organisms. There are warmth, moisture, decomposing secre- 
tions, and a harbor from the currents of air or friction of fluids and 
food that might otherwise dislodge them. 

Treatment. — Iodine internally, astringents to the surface of the 
tonsil, and injections of various drugs into the body of the gland are 
recommended for its reduction, but they are all inane makeshifts that 
worry the patient without benefit to any one but the doctor. The 



408 



TONSILLOTOMY. 



tonsil should be removed in its entirety. My aim lias always been to 
cut it clean off at the base so as to get below the bottoms of the 
crypts and leave a smooth surface for the stump. 

Tonsillotomy. — Before operating for excision of the tonsil the 
throat should be sprayed with an antiseptic wash, such as dioxide of 
hydrogen or mercuric bichloride, — 1 to 10,000, — to remove or destroy 
any microbes that may be present. We rarely apply cocaine or eucaine, 
for the reason that it is not a very painful operation. The gland is not 
freely supplied with nerves of sensation. But in very nervous indi- 
viduals it may be necessary to employ a weak solution for the purpose 




Fig. 192. — The author's tonsillotome, with excised tonsil. 



of a placebo. Occasionally I have been obliged to use the bromide of 
ethyl, removing both tonsils and adenoids during one ansesthesia. 

The patient, if a young child, is seated on the lap of an assistant 
or a nurse. One arm of the latter pinions the arms of the child, and 
with the other hand the patient's head is held back against the nurse's 
shoulder by pressure on its forehead. A convenient method is to 
infold the child in a sheet, which is made to fix immovably the arms 
and legs (Fig. 187). Now the tonsillotome (Fig. 192) is introduced 
into the mouth like a tongue-depressor, then turned to one side with 
a movement that causes the ring of the opening to surround the 
tonsil. Sufficient pressure is then exerted to cause it to embrace the 



TONSILLOTOMIES. 409 

tonsil at its base. An assistant should press with his thumb or finger 
upon the side of the neck just over the base of the gland so as to 
prevent it from receding from the instrument. This counter-pressure 
need not be great, but simply sufficient for support. As the instru- 
ment is pressed into position, the operator's thumb drives the blade 
through the gland until the cutting-edge of the guillotine rests be- 
tween the ring-plates. This act completely severs the tonsil and se- 
cures it between the bevel of the knife and the upper ring-plate. 
Care must always be taken to cut the tonsil clear through before 
withdrawing the instrument. 

Tcnsillotomes. — Any physician who has had a considerable ex- 
perience in tonsillotomy with the various tonsillotomes will not be 
likely to deny that these instruments are generally too complicated. 
They are armed with needles, barbs, or sharp-toothed forceps for 
piercing the tonsil and dragging it through the fenestra before any 
cutting is done by the blades. A tonsillotome constructed after the 
pattern I have designed renders the barbs unnecessary. It reduces 
the painfulness of the operation by one-half; it divests the procedure 
of any danger of an accident to the operator or patient; it makes a 
skillful and easy operation possible with a minimum amount of ex- 
perience; it resembles a large, folding tongue-depressor so closely 
that children usually offer no opposition to its introduction for the 
removal of the first tonsil; and it combines strength and compactness 
with simplicity of construction. It is made on the principle of a 
guillotine, the blade of which is propelled by the thumb of the same 
hand that grasps the handle. The latter is set at such an angle to 
the shaft as will permit the most perfect co-ordinate action of the 
muscles of the hand and arm of the operator. I have had two sizes 
manufactured, the smaller having a fenestra of the calibre ordinarily 
found in such instruments, the other supplied with an aperture larger 
than the largest Mackenzie tonsillotome, while it is so compactly con- 
structed as to require less space in which to operate. I have used 
the larger size to extirpate enormously hypertrophied tonsils in chil- 
dren as young as 2 1 / 2 years, where it was impossible to insert the 
Mackenzie instrument of the necessary size. The smaller one is suffi- 
cient for the majority of cases, but the fenestra is not capacious 
enough to admit the bases of the extraordinary glands we occasion- 
ally see. It is advisable to remo\e the whole tonsil, and, as the tops 
only of the largest tonsils can be severed with the smaller, instruments, 
it may be better to have the larger size, if but one is to be kept. 



410 TONSILLOTOMIES. 

The blade is so protected as to make it impossible to wound the 
ascending pharyngeal or the internal carotid artery. The shaft that 
propels the blade ^s of such a width as to make the use of a gag un- 
necessary, for it protects the finger of the operator from the patient's 
teeth, if it is placed in the mouth to ascertain when the fenestra is 
in such a position as to embrance the whole tonsil, as it is necessary 
for one to do when operating in children with other tonsillotomes. 
Since I have used this guillotine I have not had my finger bitten, 
while it was not an uncommon occurrence, before, to come off sec- 
ond best so far as pain was concerned. With the shank wide enough 
to afford protection, it is unnecessary to introduce the finger into the 
mouth, for the teeth and lips cannot close enough to prevent the 
operator from seeing plainly the field of operation. There is no work- 
ing in the dark or fear of damaging structures one does not wish to 
attack. 

The handle is firmly fixed to the shank with a hinge-joint and 
self-acting spring-lock; so that the fenestra can be pressed down 
about the base of the gland with any degree of power required. This 
feature dispenses with any necessity for hooks, forceps, needles, or 
barbs for spearing the tonsil. The latter, being a soft, fleshy mass, 
adapts itself to the shape of the fenestra and protrudes through it the 
instant its base is pressed around. The pain of spearing or tearing 
the tonsil by toothed or barbed accessories, designed to drag the gland 
through the fenestra before the blade cuts, excites the most vigorous 
struggling and resistance on the part of a child. Even when the 
utmost care has been exercised, the barbs have pierced the soft palate 
or the surgeon's finger, instead of the tonsil. Moreover, the gland 
always comes out with this instrument, the same as though barbs 
were used. There is another important advantage in having the 
handle attached to the shank with a hinge provided with an auto- 
matic lock, for the cutting extremity of the instrument cannot be 
thrown out of your control by a disturbance of the coaptation of its 
parts. The last time I operated with a Mackenzie tonsillotome the 
child jumped just as I was placing the fenestra about the tonsil. 
The shank revolved upon the handle, leaving the latter in my hand, 
while the cutting-end was entirely displaced and removed from the 
vicinity of the gland. It is impossible for this improved tonsillotome 
to play such a trick. The handle contains a concealed spring-lock 
operated by a convenient thumb-plate. When this is moved down- 
ward, the hinge-joint is unlocked and the instrument folds upon itself 



OPERATIONS OX THE TOXSILS. 411 

like a pocket-knife, occupying the space of about one and one-fourth 
inches in width and thickness by six and one-half inches in length. 
Another pertinent point, that should not be neglected in this age 
of antisepsis, is the provision for cleansing and disinfecting the three 
pieces of which the instrument consists. By raising the proximate 
end of the horizontal top spring of the shaft and swinging it 90 de- 
grees to either side it becomes disengaged from its lock and liberates 
the blade from the shank. This arrangement makes it as simple as 
possible for taking apart, sterilizing, and putting together again. 

In amputating the apex of a relaxed and elongated uvula the 
blade is inverted. It is claimed by some operators that the remnant 
of the tonsil will become atrophied if its apex only is clipped, but 
I have never been able to find a good reason for half-doing the opera- 
tion. I have never seen any but healthful results from ridding the 
throat of the whole trouble at once. 

There are cases in which one may be in doubt as to whether the 
gland ought to come out or not, because there is but slight hyper- 
trophy, and the appearance of the throat does not seem to warrant 
surgical interference. But those same glands may be honey-combeci 
with deep, slit-like crypts that are packed with inspissated, decom- 
posing, irritating, caseous secretions that start the attacks of sore 
throat that make the patient's life a burden. 

It is a good rule never to part with the patient until one is sure 
that all oozing of blood has ceased. I have seen only one case of very 
severe hemorrhage, but as a number of such instances are on record 
we must always be alert for them. In the case of a student at the 
Illinois Medical College, a young man of 24 years, I had my first 
experience with profuse haemorrhage from this procedure. After I 
had operated on a number of children during the clinic and had sent 
them to the treatment-room to wait until all signs of bleeding ceased, 
the student requested me to operate on one of his tonsils. On ex- 
amination I found it only slightly hypertrophied, and remarked that 
I did not generally remove glands so little enlarged. However, Iip 
insisted that he had suffered all his life from recurring attacks of 
inflammation, and was anxious to part company with the cause of 
them. Thereupon I excised it, but was struck with the very unusual 
amount of resistance offered to the cutting-blade. It seemed like 
forcing it through creaking leather. 

As the student left the operating-chair I proceeded with my re- 
marks to the class as follows: "The haemorrhage has entirely ceased 



412 OPERATIONS ON THE TONSILS. 

in all the children and they can now go to their homes. I have re- 
moved a large number of tonsils in my various clinics and in private 
practice without seeing a case of persistent haemorrhage. We have 
never had to resort to measures to stop the bleeding. It generally 
ceases within five or ten minutes spontaneously. But in case of severe 
haemorrhage, what would you do? Excellent remedies are to be had 
in a saturated solution of tannic acid in water; an ice-cold gargle; 
pieces of ice held in the back of the mouth in contact with the bleed- 
ing surface; ice applied to the neck over the tonsil; powdered. alum 
rubbed into the tissues; a strong solution of iron persulphate applied 
on cotton or with the ringer; 2 drachms of gallic acid with 6 drachms 
of tannic acid to the ounce of water; pressure by forceps both ex- 
ternally and internally upon the tonsil, and firm compression of the 
common carotid artery. This compression reduces the supply of blood 
to the tonsil-stump and encourages faintness, and with fainting the 
haemorrhage will probably cease. 

"There is more bleeding in this young man's case than I have 
ever seen. It does not diminish. In fact, there is a constant stream 
of blood flowing into the basin. It looks as though we were to have 
cur first experience with a persistent tonsillar haemorrhage. I will 
send for ice, and exert firm, deep compression on the common carotid. 
The pallor of countenance and the beads of perspiration show the 
effect of the loss of blood. The profuse haemorrhage is probably clue 
to the fact that the recurring attacks of inflammation during the past 
years have left the gland in an indurated, fibrous condition, which 
prevents collapse of the blood-vessels. There is no history of an haem- 
orrhagic diathesis. We will deprive the vessels of their blood-supply 
until coagula form and plug their open mouths, and keep him in a 
sitting posture to assist in this and to promote faintness. We will 
not allow him to gargle fluids for fear of washing away any clots that 
may form, but give pellets of ice instead. 

"It is now forty minutes since the tonsillotomy and all haemor- 
rhage has ceased. The young man's room-mate will keep watch over 
him and inform us if there should be any return of the trouble, al- 
though I do not anticipate it if he remain perfectly quiet in bed the 
remainder of the day. He complains of feeling faint. 

"This incident illustrates the necessity of always being prepared 
for emergencies. The most successful soldier, lawyer, or doctor is 
the one whom you can never surprise." 

The young man had no further haemorrhage and made an ex- 



OPERATIONS ON THE TONSILS. 413 

cellent recovery. After these operations patients are given a spray 
of camphor-menthol in lavolin, 3 per cent., for use at home four or 
six times a clay until all soreness ceases. 

Edwin Pynchon has devised an operation by the electrocautery 
with "a current about 50 per cent, stronger than is required to pro- 
duce a white heat of the electrode in the open air. Such a current 
will give the least pain with the most rapid results." He dissects the 
tonsil away from its attachments, entering the point cold, heating 
and burning out. The electrode is used as a tenaculum, and "the 
tonsil is lifted out and toward the median line, when the point is 
heated and burns its way out. Only a little is done at a time." Op- 
erating in this way with the help of forceps the tonsil is dissected 
entirely from the pharyngeal aponeurosis. It is claimed for this opera- 
tion that there is little or no haemorrhage under cocaine. 

Jonathan Wright has devised a galvanocautery instrument fash- 
ioned after the guillotine tonsillotomy 



CHAPTEE XXXIV. 
DISEASES OF THE PHARYNX, CONTINUED. 

Mycosis of the Pharynx. 

Synonym. — Pharyngomycosis. 

Pathology. — This is a very rare parasitic disease of the superior 
pharyngeal space, including the tonsils. Small, white or yellow 
growths appear, projecting above the mucous membrane, instead of 
occupying a recessive position, as is the case with tonsillar concre- 
tions. They may invade the lacunae, but are not confined to them. 
They spread upon the soft palate, the pharyngeal membrane, and base 
of the tongue. As I have seen it, the growth is not soft like the 
cholesteatoma of the tonsil, but tough and somewhat difficult to re- 
move in its entirety. It has, in some instances, a fungoid appearance, 
and penetrates the mucosa to such a depth as to prevent its removal 
with a probe. 

Etiology. — The cause of this disease is obscure, but the micro- 
scope reveals the leptothrix buccalis, which finds a habitat in carious 
teeth. 

Symptomatology. — Xo conspicuous symptoms are produced by 
this disease, but patients discover the growths accidentally and apply 
to have them removed. 

Diagnosis. — The diagnosis is easily made, since the symptoms 
of inflammation characterizing pharyngitis, tonsillitis, etc., are want- 
ing. It is distinguished from tonsillar concretions by the prominence 
of the growths and their location without the lacunae. 

Prognosis. — The tendency is not toward a spontaneous cure. The 
disease is very pertinacious and, like the regeneration of the drum- 
head, these growths often reproduce themselves as fast as they are 
removed. 

Treatment. — If caries of the teeth is found it must receive at- 
tention. Delavan uses the curette and follows this with the galvano- 
cautery. After removing the fungi the membrane should be sprayed 
with undiluted hydrozone or mercuric bichloride, 1 to 10,000. Each 
growth should be treated as has already been recommended for en- 

(414) 



CONCRETIONS IN THE TONSIL. -115 

larged pharyngeal follicles, using cocaine and then cauterizing half 
a dozen points at one sitting. In a monograph on pharyngomycosis 
leptothricia benigna, published in the New Yorker medizinische Presse, 
December, 1886, Max Toeplitz reviews the literature of the subject. 
Carbolic acid, sesquichloride of iron, and the sublimate solution, 1 
to 2000, are recommended. Toeplitz uses the curette and galvano- 
cantery. Homer M. Thomas also reports success from the galvano- 
cantery. 

Concretions in the Tonsil. 

Pathology. — The crypts of the tonsil are sometimes filled with 
an accmnnlation of dried secretions that consist mostly of carbonate 
and phosphate of lime in the hard variet}-, and of a cholesteatomatous 
mass in the soft deposits. The latter consist of cholesterin, epithelial 
cells, pns-corpnscles, and micro-organisms. The hard concretions are 
called chalky or cretaceous concretions or calculi, and the soft ones 
cheesy or caseous deposits. These conditions are comparable to cer- 
tain diseases of the ear that have been considered: cretaceous deposits 
in the drum-head and cholesteatoma of the tympanic and mastoid 
cavities. 

Etiology. — Tonsillar deposits are due to an inflammation of the 
walls of the lacunae. 

Symptomatology. — The symptoms are not of a troublesome 
nature. A sensation of irritation or fullness, especially when swallow- 
ing, may be the only unusual thing to be noticed. The deposit can 
generally be seen as a cheese-like point, and several will likely be 
found by a careful examination. Sometimes they will be overlooked 
unless hunted for by a blunt-pointed probe to depress and bring for- 
ward the mouth of each opening. The difference in the consistence 
of the masses is readily detected by the sensation imparted through 
the probe. Patients often observe these concretions in their sputa, 
with which they have been expelled in the form of little, yellowish 
balls. Their presence is a menace to the health of the gland, for they 
degenerate into irritating excitants of inflammatory processes. 

Treatment. — With the tongue depressed these concretions are 
removed without difficulty by the curette (Fig. 80). If they are re- 
produced the crypts should be treated to the hot electrode or some 
other cautery. H. W. AVhitaker uses a 50-per-cent. solution of tri- 
chloracetic acid on a cotton-carrier for destroying the secreting sur- 
faces of the tonsillar crypts (Tlie Laryngoscope, November, 1897). 



416 TUMORS OF THE PHARYNX. 

NON-MALIGXAXT TUMORS OF THE PHARYNX. 

Tumors of the pharynx are not of frequent occurrence. I have 
seen many papillomata springing from the velum palati and uvula, 
varying in length from five to ten millimetres, but of pretty uniform 
diameter, this being about one-half their length. Fibroid and fatty 
tumors are rarely found, but such cases are recorded. They take their 
origin from the mucous or submucous tissue, from the lymphatic 
glands, or from the periosteum of the base of the skull or vertebrae. 

Symptomatology. — A papilloma occasions no discomfort. The 
patient is not often aware of its presence until informed by the ex- 
aminer. If a tumor attain to a considerable size it embarrasses res- 
piration and swallowing, or, if it reach to the epiglottis, it provokes 
a cough. 

Treatment. — If papillomata give trouble they are easily removed 
by the knife, scissors, snare, or galvanocautery. Other tumors must 
be treated similarly, according to the exigency of each case. 

Adhesions of the Soft Palate to the Pharyngeal 

Walls. 

Adhesions of the soft palate to the posterior wall of the pharynx 
sometimes occur, but they are rare. In one of my cases, shown 
in Fig. 193, the young lady's throat is divided into superior and in- 
ferior portions by an adventitious membrane consisting of extensive 
adhesions between the posterior columns and arch of the palate, on 
the one hand, and the lateral and posterior pharyngeal walls, on the 
other. An oval aperture is seen behind the uvula, through which 
nasal respiration takes place. The only inconvenience suffered is the 
lodgment of particles of food behind the new membrane. This apo- 
neurosis, or pharyngeal diaphragm, is the result of the throat affection 
attending scarlatina, which she had when a small child. 

ITvulitis. 

Inflammation of the uvula is sometimes more intense than the 
inflammatory action affecting the remainder of the pharynx. The 
swelling, oedema, and elongation of the uvula, then constitute the 
conspicuous features of the disease. It increases to several times its 
normal proportions and hangs pendent upon the tongue, down toward 
the larynx. In this condition it gives rise to frequent swallowing and 
coughing (Plate IV, tfo. 8). 



UVULITIS. 



417 



Treatment. — If the uvula is much elongated (Plate IV) it should 
he clipped, with care that not enough he amputated to leave it too 
much abbreviated when swelling recedes and contraction takes place. 




Fig. 193. — Adhesion of soft palate to the posterior wall of the pharynx. 

The resulting diaphragm is perforated behind the uvula. 

(The author's case.) 



418 



BIFID AXD DOUBLE UVULAS. 



I have known it to be completely removed by mistake, probably on 
account of the operator's poor sight, and the articulation of words 
was perceptibly defective. On the other hand, I have known syphilis 
to destroy it without producing this effect. 

Bifid and Double Uvulas. 

Considerable interest has been manifested of late in the subject 
of cleft uvulas, and a number of articles in the medical journals have 




Fig. 194. — Bifid uvula in a man sixty years old. (Author's case.) 



given it much prominence. Some of the writers have maintained 
that these abnormalities are exceedingly rare, and that they call for 
prompt surgical interference to effect the removal of the super- 
numerary members. 

These anomalies are certainly not common, but the examinations 
of a very large number of throats in Chicago have given the author 



BIFID AND DOUBLE UVULAS. 



419 



the opportunity of seeing quite a large number of such eases. In 
nearly all instances the uvula is bifid somewhat as shown in Fig. 194. 
a photograph of a man 60 years old. AVe very rarely find two com- 
plete uvulas, as seen in the boy, 14 years old, in Fig. 195. More 
than 50 per cent, of the cases that have come under my observation 




Fig*. 195. — Complete double uvula in a boy of fourteen years. (Author's case.) 



show a division not to exceed one-half of the entire length of the 
uvula, and many of these show a bifurcation extending not more than 
one-third of its entire length. The upper portion of the uvula was 
often normal until about its lower one-fourth was reached. . This 
branched out into two extremities with a mere notch of greater or less 
depth between them. 



420 TUBERCULOSIS OF THE PHAKYNX. 

In some instances the two portions of the uvula were of unequal 
length, one being sufficiently elongated to lie upon the dorsum of 
the tongue. Speech was not perceptibly impaired, and no difficulty 
in deglutition was found. A. H. Ohmann-Dumesnil (The Laryngo- 
scope, October, 1897) claims that "the entire absence of the uvula is 
of much more frequent occurrence than a double one." The author's 
experience is the reverse of this. Congenital absence of the uvula has 
been rarely seen by him, although its absence through pathological 
causes is not very infrequent. 

The author has taken pains to question this class of patients 
relative to any inconveniences which they may have experienced from 
the conditions of their uvulas. With only a few exceptions they were 
entirely unconscious of the existence of any such anomaly. A few 
of the most intelligent and observing ones had discovered it and re- 
garded the cleft as a mere curiosity. 

Bifid and double uvulas are anomalous, rather than diseased, 
conditions. They are undoubtedly closely associated with those cir- 
cumstances which cause cleft palate, and, as Trelat believes, they 
are, to an extent, hereditary. In Fig. 195 the process approaches very 
nearly to that which eventuates in cleft palate. 

Treatment. — The author cannot agree with those writers who 
advocate trimming or amputating these supernumerary uvulas, in 
the absence of any definite indications for surgical procedures. The 
owners of these extra appendages were generally innocent of a sus- 
picion that there was an unusual condition of their throats. If the 
elongated branch or branches tickle the tongue and cause cough- 
ing, the same reasons exist that we have in the same conditions of 
single uvulas for clipping the relaxed or elongated ends; but there 
is no occasion for the operation for cosmetic purposes. Here, as 
elsewhere, the knife should not be resorted to "without just cause or 
provocation." 

Tuberculosis oe the Pharynx. 

Tubercular invasion of the throat is of infrequent occurrence. 

Pathology. — A granular condition of the mucous membrane of 
the pharynx, showing areas of a gray color, precedes the breaking 
down of the epithelial layer that ushers in the stage of ulceration. 
The ulcers are superficial, of irregular forms, and ill-defined. Like 
a granulating wound, they respond to the touch by bleeding. (See 
"Pathology," under "Tuberculosis of the Larynx," page 494.) 



TUBERCULOSIS OF THE PHARYNX. 421 

Etiology. — The throat invasion is generally secondary to the same 
affection of other organs. 

Symptomatology. — The cough, constantly-elevated temperature 
and accelerated pulse, loss of appetite and the characteristic expression 
of countenance, pallor of skin, and the habit of the body point toward 
the invasion of the great white plague. If the lungs are involved 
there will be expectoration, with cough; if not, the cough may be, 
at first, dry and hacking. The most conspicuous and distressing symp- 
tom is pain, especially during movements of the muscles concerned 
in deglutition and speech. The proper nourishment of the patient is 
interfered with by the difficulty and pain experienced in swallowing. 
He will refrain as long as possible from taking food, in order to 
escape the torture of eating. Inspection reveals the granular, or 
ragged, ulcerated condition of the mucous membrane already de- 
scribed. 

Diagnosis. — Tubercular throat must be distinguished from syph- 
ilitic ulceration. The history of syphilis and the family history of 
tuberculosis must be sought. The latter disease is usually one of 
adult life, while syphilis, especially the congenital form, may occur 
in children. Syphilis is not attended by fever, and generally not 
by pain or very difficult swallowing. Its ulcers are clearly defined, 
with red areola and clean-cut borders possibly undermined. The 
ulcers of tuberculosis are shallow, ragged, and pale. They differ from 
scrofulous ulcers in that the latter are deep, with well-marked bor- 
ders, and pain, fever, and cough are generally absent, while the mus- 
cles of phonation and deglutition cause little or no pain by their move- 
ments. The scrofulous affection occurs mostly in children in whom 
there are no evidences of tuberculosis. 

The following points in the differential diagnosis between tuber- 
culous and syphilitic ulcers are given by Lennox Browne: — 

Tuberculous Ulcers. Syphilitic Ulcer*. 

No apparent excavation. Deeply excavated. 

Much indolent granulation. Few granulations, and those highly 

inflammatory. 

Faint areola. Deep-red areola." 

Irregular and ill-defined edges. Sharply-cut ed»es. 

Demarkation indistinct. Demarkation distinct. 

Grayish, ropy, mucous secretion. Yellow, purulent secretion. 

Discharge scant. Discharge copious. 

Superficial, with lateral, instead of Penetrating to deep tissues. 

deep, extension. 

Fever. Xo fever. 



422 TUBEECULOSIS OF THE PHARYNX TREATMENT. 

Prognosis. — This is an acute affection that proves quickly fatal 
from exhaustion. The average duration of the disease varies from six 
weeks to six months, but it may be prolonged much beyond the latter 
time. 

Treatment. — For the relief of the most prominent symptom, pain, 
Sajous strongly recommends the application of a 10-per-cent. solu- 
tion of cocaine, after cleansing the ulcers with a borax solution of 1 
per cent, in the form of a spray ("Diseases of the Nose and Throat," 
1892). He deprecates cauterization with silver as more hurtful than 
beneficial. Steam-inhalations of hot infusions of opium, belladonna, 
hyoscyamus, and conium produce a soothing, sedative effect and ren- 
der swallowing less painful. A solution of creasote and menthol in 
lavolin, in the proportion of 2 per cent, of creasote to 10 per cent, 
of menthol, makes an excellent topical remedy. Iodoform insuf- 
flations have proven beneficial, but aristol is preferable. It is devoid 
of a disgusting odor and taste, is slightly anaesthetic, and adheres to 
the surfaces of the ulcers better than any other powder. Before ap- 
plying any of these local remedies the discharges covering the ulcer- 
ated surfaces must be washed off by hydrozone or such an alkaline 
spray as DobelFs or Seller's. A solution of sodium bicarbonate, 3 
grains to the ounce, is also useful for this purpose. The cauteriza- 
tion of tuberculous ulcers by acetic acid, as practiced by Krause, is 
probably productive of more benefit than any other method. The 
ulcers are treated similarly to lupus. After cleansing and cocainizing 
them the acid is rubbed in by means of a cotton pledget, using a 
solution of 20- to 40-per-cent. strength, to begin with, and increasing 
the strength rapidly to 80 and 100 per cent. As fast as the eschars 
become detached, which they do in a few days, the Treatments are 
repeated, until the process of cicatrization is seen to begin. If the 
tubercular granulations are covered with mucous membrane the latter 
must be incised to give the acid access to the lesions beneath. Heryng 
uses sharp curettes to scrape away projecting masses of tumefied 
tissues. 

Cicatrization sometimes follows this method, but close watch must 
be kept for renewed breaking out of the disease in either the cicatrices 
or at new points. 

J. Solis-Cohen condemns galvanocauterization as injurious "ex- 
cept under the most skillful manipulation." 

Ingals makes use of either the following spray or morphine 
troches: — 



TUBERCULOSIS OF THE PHARYNX TREATMENT. 423 

I£ Morphias sulpliatis. gr. iv. 

Acidi tannici. 

Aeidi carbolici, of each, gr. xxx. 

Glycerini, 

Aquae dest.. . . . . . .of each, f^ss. 

Tuberculin and tuberculocidin have not fulfilled the expecta- 
tions of the profession. The former has proven positively harmful, 
and since patients do as well under other forms of treatment as with 
the use of the latter, their employment is not recommended. 

Creasote has been largely used internally and applied locally in 
recent years, and, while undoubted benefit has accrued from its use 
in the hands of eminent practitioners, there are some who discourage 
its employment. However, in a disease so intractable, and discour- 
aging to both patient and physician, as this must be admitted to be, 
whatever has proven beyond cavil and reasonable doubt to have been 
helpful in treatment is worthy of trial. Great caution is necessary 
in its administration to patients who have high temperature or haem- 
orrhages. It is given in doses of 1 to 10 minims or more three times 
a day, preferably in milk, as recommended by Glasgow. It can be 
given at any time with reference to meals, but is best taken before 
meals if well borne, since it then exercises a preservative influence 
upon ingested food against the process of decomposition. The effect 
of this upon the promotion of nutrition is apparent. 

Creasote is readily taken in the form of capsules, or it may be 
combined with alcoholic or tonic preparations, as used by Cohen. 

The feeding of this class of patients is an important subject. 
"When the high temperature does not forbid much animal food, as 
much should be consumed as is consistent with good digestion. Milk, 
cream, codliver-oil, eggs, and vinous stimulants support the strength, 
improve nutrition, and prolong life. Added to these, the vegetable 
bitter tonics, iron, and quinine act as valuable aids to enrich the blood 
and increase the general tone of the body. 

An out-door life in a high, dry, sunshiny, warm climate, with 
equable temperature, is conducive to the improvement of these pa- 
tients, especially when combined with proper protection of the body 
by woolen underwear and a healthful employment of the mind and 
body in a cheerful or useful occupation. The most favorable climates 
are those of Southern California, Arizona, and Xew Mexico. Robert 
Levy says of Colorado: "I cannot add that our Colorado climate, so 
beneficial to pulmonary and. at times, to laryngeal phthisis, has anv 



424 SYPHILIS OF THE PHARYNX. 

remedial influence upon pharyngeal tuberculosis. Miliary tubercu- 
losis, with which tubercular ulceration of the pharynx is often asso- 
ciated, presents no encouragement in any climate, but in our high 
altitude it is my conviction that cases so afflicted decline very rapidly. 
The climate can only be of value in such cases as present no evidences 
of miliary tuberculosis or advanced disease, either local or constitu- 
tional." (Denver Medical Times, June, 1896.) 

Syphilis of the Pharynx. 

Although the throat is subject to the manifestations of syphilis 
in the three stages of that disease, the primary lesion is not often 
•observed in this locality. The history of chancre in the pharynx 
is similar to that of the same ulcer in other localities, with a duration 
of about six weeks. The secondary lesions are of frequent occurrence 
.and the characteristic mucous patches are readily recognized. The 
tertiary stage is represented by the presence of gummata or eroding 
ulcers. The congenital form generally shows itself about five or six 
weeks after birth by the appearance of secondary lesions, and the 
tertiary stage at any time preceding the fifteenth or sixteenth year. 

Pathology. — Chancres are generally found on one tonsil, while 
the secondary and tertiary lesions show a special predilection for the 
soft palate. The syphilitic eruptions of the throat are similar to those 
occurring in other parts of the economy and are often coincident with 
them. In the early stage papular elevations make their appearance, 
the epithelial covering of which becomes eroded; or erythematous 
patches occur in the form of a blush or mere hyperemia of transi- 
tory duration; or the epithelium of these areas becomes exfoliated, 
leaving a denuded, pus-secreting mucous membrane beneath. These 
mucous patches now assume an ashy-gray color, with a rough, granu- 
lar surface. They are eruptions of the secondary period of syphilis 
and extend their boundaries so as to invade a large territory in a 
comparatively brief period. They are surrounded by a red areola and 
a well-defined border, and there is a copious, purulent, nasty discharge 
from them. 

In the tertiary stage the ulcers are deeper than the mucous 
patches of the secondary period. The infiltration extends to the whole 
depth of the membrane and results in irregular thickening and indura- 
tion in the form of nodules or gummata. If these are incised in the 
early stage they exude a glairy fluid. In time they degenerate into a 
caseous mass, which becomes surrounded by dense connective tissue. 



SYPHILIS OF THE PHARYXX. 



425 



They are closely analogous to tubercle, but differ from the latter in 
their greater tendency to the formation of connective tissue. The 
increased proliferation of connective tissue produces pressure on the 
blood-vessels that supply the gummata with nutrition, thus cutting 
off their own nutrient sources. Breaking down and softening follow 




Fig. 196— Large perforation of the velum palati. The lower border is 
covered with a light-colored discharge. Perforation closed en- 

( Author's case.) 



tirelv in three months. 



in each gumma, presenting a yellow spot which is soon the seat of an 
ulcer. 

The mucous patches of the secondary stage are superficial and 
may end in resolution with contraction of the tissues as the cicatrix 
forms. The tertiary ulcers may occur in any part of the pharynx. 
They extend rapidly and deeply, perforating the pillars of the fauces 
or the velum (Fig. 196) in a few days, and gradually eating away the 



426 SYPHILIS OF THE PHARYNX. 

whole veiling uvula, and faucial columns, as illustrated by one of my 
cases in Fig. 197. 

Etiology. — The specific virus of syphilis is yet one of the un- 
known quantities in medicine, notwithstanding the fact that a con- 
siderable percentage of humanity are, or have been for many genera- 




Fig. 197.- — Destruction of the velum palati. 

tions, infected by it. The occurrence of the primary lesion in the 
mouth or pharynx is generally in consequence of kissing or of using 
utensils not thoroughly cleansed after having been used by syphilitics. 
They may also result from certain practices of sexual perverts. The 
secondary stage of syphilis is quite generally accompanied by throat 
lesions, and next to the genital organs the throat is the most fre- 



/ 



SYPHILIS OF THE PHARYNX. 42? 

quently affected. Tertiary manifestations may crop out in the 
pharynx a quarter of a century after the appearance of the initial sore, 
but the average interval is about seven years ("the perfect number'?). 

Symptomatology. — The primary lesions of the throat are at- 
tended with so slight a disturbance that they are altogether likely to 
be overlooked. The submaxillary lymphatic glands may be enlarged 
and tender to the touch. Inspection discloses a red, or perhaps a 
gray, denuded spot with prominent edges. It generally disappears- 
spontaneously. As already remarked, the initial lesions are mostly 
found on the tonsil. 

Fournier "recognized syphilitic ulcer of the tonsil in 40 per cent, 
of his cases of ulcers of the mouth. The sore is generally single, and 
sometimes covers the whole tonsil, occasionally extending to the 
pillars of the fauces and to the base of the tongue. The erosive form 
is the most common. The symptoms are trifling, but the ulcerative 
form causes pain and difficult swallowing; the ulcers are brown, gray,, 
or yellow and the tonsil is indurated/' Occasionally there is some 
systemic disturbance. 

Secondary symptoms manifest themselves as an erythema or as 
mucous patches on one or both sides of the throat. The erythematous 
eruption occurs either in blotches, suggestive of the roseola, or it may 
appear as a diffused redness spreading over the whole pharynx. This 
stage is attended with the usual symptoms of simple sore throat. 
After a few days distinct patches are clearly made out on the anterior- 
columns or on the velum and other parts of the throat or mouth. 
The sides of the tongue near its base are especially liable to suffer. At. 
first these mucous patches appear as slight, rounded elevations of a 
dark-red color. Their centres soften and break down, leaving a 
characteristic, slightly-cup-shaped excavation, which later assumes a 
gray color. In this stage swallowing is attended with pain. 

The tertiary lesions generally begin by attacking one tonsil and 
the adjacent faucial pillars. The nodular and gummatous points- 
begin to show signs of breaking down, then the epithelial layer cover- 
ing them grows thin, revealing a yellow spot underneath. Finally 
the epithelium is exfoliated, exposing an ulcerating process which 
penetrates the mucosa deeply, leaving an accentuated cup-shaped de- 
pression surrounded by uneven, but prominent, ragged edges. These 
ulcers are rapidly destructive to the soft tissues, and do not seem to 
be retarded in their erosive action by cartilage or bone. I have seen 
them perforate the soft palate in a few days, and for a time no treat- 



428 SYPHILIS OF THE PHARYNX. 

ment would stay their progress or appear to produce any impression 
whatever. The whole soft palate is sometimes destroyed, as I have 
seen in a series of cases (Fig. 197). Cicatricial contractions have the 
effect of narrowing the lumen of the throat, and adhesions may en- 
croach seriously upon the upper part of the pharynx or even shut it 
off from the lower part by adhesions of the soft palate to the posterior 
pharyngeal wall, similarly to the condition shown in Fig. 193. 

It is somewhat remarkable to observe the trivial character of 
the subjective symptoms as compared with the extensive gnawing 
away of the structures of the throat. I have seen this corrosive proc- 
ess plowing through the faucial columns and the velum, leaving per- 
forations, eating away their borders until several small apertures 
united into one large hole, destroying one of the supporting shreds 
of the velum, and allowing the ragged remnant to drop and hang as 
a pendant, swaying and fluttering with the currents of the air. Pa- 
tients subject to these erosions sometimes appear to experience less 
inconvenience 'from them than others suffer from a common cold. 
But in other individuals much pain attends the process, and swallow- 
ing causes a distressing effort. Solids must be eschewed and the diet 
confined to liquids until amelioration of the condition can be effected. 

Diagnosis. — This disease may be mistaken for tuberculosis, and 
in the early stage may be confounded with a simple catarrhal inflam- 
mation of the mucous membrane. But the latter yields readily to 
treatment, while the syphilitic disease progresses uninfluenced by any 
other than specific treatment. 

In tuberculosis serious constitutional disturbances are present, 
such as are not accompaniments of syphilis: fever emaciation, etc. 
The areas of hyperamiia that later become the seat of ulceration are 
paler and softer in tuberculosis than in syphilis. The ulcers of 
syphilis have more regular, clearly defined borders and are deeper 
than in tuberculosis. The pain of the latter disease, especially in 
swallowing, causes great suffering, while it is not a prominent symp- 
tom of syphilis and may be absent altogether. The patient improves 
and gains in weight on specific treatment in syphilis, but grows worse 
in tuberculosis. The presence of pulmonary tubercular lesions will 
aid in clearing up the diagnosis. 

Prognosis. — The primary sore disappears in about six weeks. 
The secondary lesion is about that time in coming on after infection 
and lasts approximately the same length of time when left to nature. 
The third stage is far more serious, for, while the primary and sec- 



TREATMENT OF SYPHILIS OF THE PHARYXX. 429 

ondary periods may not menace health or life, the tertiary form in- 
vades all tissues with a wanton destruction that is sometimes appalling. 
Important structures are not immune. A large blood-vessel may be 
opened and cause a fatal haemorrhage. Contractions of cicatricial 
tissues may constrict the throat and seriously interfere with breath- 
ing, swallowing, and speaking. 

Treatment. — Cleansing solutions should be used on the ulcerating 
surfaces before local applications will be of any avail. For this pur- 
pose I have had satisfactory results from hydrozone and the alkaline 
antiseptic solutions of Dobell and Seiler, in the form of a coarse spray 
with sufficient force to the stream to dislodge and wash awajr all the 
dirty secretious. These are good, cleansing, soothing sprays for the 
primary lesions and the erythema also. Then I touch the denuded 
surface with tincture of iodine, pure, by means of a small cotton 




Fig. 198. — Small powder blower with long tube. It can be operated 
by a small rubber bulb, also. 

pledget twisted hard upon the silver applicator. When the iodized 
cotton is pressed upon the ulcerating part, not enough of the tincture 
should be left to run down over the healthy membrane. This treat- 
ment is usually followed by a drying up of the discharges and the 
institution of a healthy granulating process. 

If the throat is exceedingly painful, especially upon swallowing, 
one is justified in painting it with a -i-per-cent. solution of cocaine 
just before meals, to insure sufficient ingestion of food to support the 
strength. After cleansing and drying the ulcers with absorbent cot- 
ton, we cover them with a coating of aristol or nosophen by means of 
a small powder-blower (Fig. 198). The antiseptic and slightly anaes- 
thetic effects of aristol, besides its power of promoting granulation 
formation, have seemed to me to transcend the properties of any other 
single remedy. Sajous cleanses with a solution of potassium perman- 
ganate, and uses zinc sulphate or lead acetate, in a 5-grain solution, 



430 CANCER OF THE PHARYNX. 

for their astringent effect, or 5 minims of the tincture of the chloride 
of iron in a drachm of glycerin. Mackenzie used 20 grains of the zinc 
chloride to the ounce for the erythema, and tincture of iodine for the 
mucous patches. If the ulcers were indolent he preferred copper sul- 
phate, 15 grains to the ounce. In the secondary and tertiary periods 
I employ mercury and potassium iodide, the mixed treatment, and 
tonics, with whatever general treatment the condition of each patient 
suggests. 

Cancer of the Pharynx. 

Synonym. — Carcinoma of the pharynx. 

Pathology. — Cancer of the superior portion of the pharynx is 
generally of the scirrhous form, and presents, in its early history, an 
indurated mass not clearly defined in its circumference. At first the 
mucous memhrane covering it may not show any visible changes. 
The growth may extend to include the soft palate and pharyngeal 
vault. As the epithelium breaks down and ulceration of the surface 
of the tumor begins, a fetid exudate bathes the surface, which assumes 
a red or light-greenish appearance. Large, pedunculated granulations 
are sometimes to be seen, during this carious process, springing from 
the floor of the ulcer. The submaxillary lymphatic glands become 
infiltrated early in the attack. 

When the cancer is situated in the lower part of the pharynx, 
or the pharyngo-laryngeal cavity, it generally takes on the character 
of epithelioma. Its most usual site is a little below the arytenoid 
cartilage. Instead of the red or light-greenish surface of ulcerating 
scirrhus, this variety presents a gray surface inclosed by the very red, 
tumefied, mucous membrane. The disease spreads until it circum- 
scribes the passage. 

Etiology. — Heredity is the only known cause of this disease. 

Symptomatology. — Inspection reveals the presence of a tumor 
or an ulcerating surface. The symptoms are characteristic of a lesion 
obstructive to respiration and deglutition. Phonation is interfered 
with, the speech is thick, and there is a foul-smelling, frothy ex- 
pectoration. Swallowing is painful, but the suffering is not limited 
to this act, being constant and sometimes extending to the Eusta- 
chian tubes and ears. 

Diagnosis. — This is not obscure. It is possible to mistake this 
for a syphilitic lesion, but the use of mercury and potassium iodide 
will remove all doubt. In a case recently under my observation the 



TREATMENT OF CANCER OF THE PHARYNX. 431 

attending physician was not able to reach a conclusion. I suggested 
that a mixed treatment would soon result in recovery, which in a 
few weeks followed, demonstrating the specific nature of the lesion. 

Prognosis. — Sooner or later death closes the scene. 

Treatment. — Hitherto, palliative measures have formed the chief 
reliance of the physician. If death is impending by obstruction to 
respiration, intubation or tracheotomy may prolong life. Nourish- 
ment may be administered by the oesophageal tube or by enemata, 
when swallowing is obstructed. Cocaine, morphine, and sedative 
sprays afford temporary relief only. 

Thomas Hubbard reports, in the Journal of the American Medical 
Association, June 13, 1896, a case of squamous epithelioma of the 
velum palati cured by injections of caustic potash by a curved plati- 
num needle. Injections were repeated wherever proliferating epi- 
thelial growths were seen. Cicatrization was rapid as well as the gen- 
eral improvement. The case remained cured after two years. 

Karl Schwalbe, 0. Hasse, and others have advocated injections 
of alcohol into cancerous growths as a curative measure, and in- 
stances have been reported in which complete cures have been claimed 
as the result of these interstitial injections. As having a direct bear- 
ing on this subject, we will refer to the following observations of 
Hasse, which cover a broad field: -"Alcohol favors cicatrization in all 
growths like struma, angioma, cysts, lymphatic-gland tumors, sarcoma, 
carcinoma, and especially carcinoma of the breast and cervix uteri. 
Under its use, in fifteen out of eighteen cases of carcinoma of the 
breast, the growth gradually dwindled away until in a year there was 
nothing left but the connective-tissue stroma, and there has been no 
return. Five cases of carcinoma of the cervix also recovered com- 
pletely, and the patients are still living and in good health. The 
effect on the general health is even more surprising. The pains and 
uneasiness pass away, and sleep, appetite, assimilation, and strength 
return in a most remarkable manner." This method of treatment has 
been applied to cancer of the naso-pharynx with promising results, 
and should, be given extensive trials to definitely determine its lim- 
itations of usefulness in this field. 

Schwalbe and Hasse reasoned that if alcohol would produce con- 
traction and atrophy of tissues, as occur in the cirrhotic liver of the 
inebriate, it would have a similar effect on a neoplasm into the paren- 
chyma of which it might be injected. While the former believes that 
its curative effect is produced, when injected into the interior of the 



432 TREATMENT OF CANCER OF THE PHARYNX. 

tumor, by causing the formation of new connective tissue, with the 
obliteration of blood-vessels, lymphatics, and the parenchyma, Hasse 
practices injection into the circumference, maintaining that the new 
connective-tissue formation, girdling the periphery of the growth, 
would choke the afferent and efferent blood-vessels and thus cause- 
atrophy. 

Hasse employs a Windier syringe, but others prefer a Pravaz. 
The alcohol is used in the strength of 30 to 50 per cent. At first 
but a small quantity may be endured, for the injections are very pain- 
ful, but the quantity may be increased gradually from 6 to 30 or 
40 minims. 

The object of the interstitial injections is to surround the tumor 
with alcohol so as to cause contraction of the connective tissue, fatty 
degeneration of the cancer-cells, and obliteration of the blood-vessels.. 



CHAPTEK XXXY. 
DISEASES OF THE PHARYNX, CONCLUDED. 

Eetkophaeyngeal Abscess. 

Etiology. — Abscess in the posterior pharyngeal wall may result 
from acute inflammation of the pharynx or of the submucous tissue 
and glands; from a middle-ear suppuration in consequence of the 
pus breaking through the anterior wall of the tympanic cavity or 
through the semicanal for the tensor tympani muscle, and from a 
disease of the vertebra?. It is more likely to occur in the strumous 
or syphilitic, and may be a sequel of the eruptive fevers or diphtheria. 
Traumatism resulting from the swallowing of fish-bones, the impact 
of a lead-pencil, etc., or scalding liquids and destructive chemicals 
may give rise to retropharyngeal abscess. 

Symptomatology. — If the abscess is located in the upper and 
back part of the pharynx there is a sensation of fullness accom- 
panied by obstruction to nasal respiration with nasal voice. The 
tumor may be seen in this locality with the rhinoscopic mirror, and 
if it is not too high it may become visible by using the palate- 
elevator (Plate Y). On passing the finger into the vault of the 
pharynx it meets with a resistance which may be mistaken for adenoid 
vegetations. When it is posterior to the base of the tongue it can 
be brought into view by the use of the tongue-depressor. If the 
swelling is behind the glottis and attains a large size it is liable to 
press on the epiglottis and embarrass its functions. The swallowing 
of foods and liquids is so interfered with as to cause their entrance 
into the larynx. Dyspnoea of such a serious degree as to endanger 
the patient's life may result from an abscess in this region. Occa- 
sionally the tumefaction increases to such a size as to be visible by 
means of a swelling in the side of the neck. The inflammatory proc- 
ess may extend to the cervical glands, producing induration, pain, 
and tenderness. 

The head generally assumes a position suggestive of torticollis, 
being held fixedly to one side with the face upturned and everted. 

The general condition is one indicative of a severe illness. The 
temperature is often somewhat elevated, and thirst adds to the gen- 

28 (433)^ 



434 RETROPHARYNGEAL ABSCESS. 

eral discomfort. Like tonsillar abscess, rupture takes place usually 
into the throat. The evacuation of pus may fill the larynx and cause 
strangulation, or, if relief is not obtained early enough by incision or 
rupture, a dangerous or fatal oedema of the larynx may occur, or the 
pus may burrow among the cervical muscles and produce an abscess 
of the neck, or it gravitates to the thoracic cavity. 

Inspection shows a bulging of the mucous membrane at the 
seat of the swelling. The tumefaction and the contiguous structures 
present a dark, dusky-red hue, including the uvula and soft palate. 
Fluctuation can be felt by pressure with the finger over the bulging 
surface. 

Diagnosis. — Eetropharyngeal abscess may be confounded with 
other inflammatory affections of the throat, but the absence of cough, 
pseudomembrane, vocal changes, and ulcerative conditions of the 
mucous membrane, taken together with the presence of obstruction 
to respiration and deglutition, the unnatural fixation of the cervical 
muscles and twisting of the neck, the presence of bulging and fluct- 
uation in the walls of the pharynx proper are decisive diagnostic 
features. 

Treatment. — If seen early, ice (Fig. 83) should be applied to 
discourage pus formation. As soon as fluctuation can be made out 
the abscess should be punctured with bistoury or trochar, making an 
opening sufficient to evacuate the cavity, but not large enough to 
cause a profuse gush of the contents so as to overwhelm the patient 
by filling the larynx and causing strangulation. MacCoy recommends 
that the incision be made high enough in the swelling to necessitate 
pressure on the tumor to empty it, so as to avoid too great and con- 
tinual flow of pus. The incision should be made in a nearly vertical 
direction, leaving a small wound, so as not to favor the entrance of 
food into it during the act of swallowing. The internal carotid 
artery must be avoided by cutting toward the median line. Cocaine 
or eucaine should be painted, in a 4-per-cent. solution, over the part 
to be entered, before the operation. A trochar can be used instead 
of a knife, but care is necessary to prevent it suddenly plunging be- 
yond the abscess, as the wall yields, and injuring the parts beyond. 
The vertebrae are easily damaged by such an accident. The instant 
the abscess is opened the patient's head should be thrown forward 
to avoid the flowing of pus and blood into the larynx. The part of 
the knife-blade that is not to enter the tissues is protected by twist- 
ing cotton firmly around it as is done on the cotton-carriers. 



NEUROSES OF THE PHARYNX. 435 

The blood is likely to be found impoverished, demanding iron 
and a nutritious diet. Alteratives containing iodine and the bitter 
tonics are useful. The throat should receive proper attention until 
the wound heals, and any abnormality present should be corrected. 

Neuroses of the Phaeyxx. 

There are two varieties of neuroses affecting the pharynx, — one 
of sensation, the other of motion. 

NEUROSES OF SENSATION. 

These affections are of four kinds: hyperesthesia, anaesthesia, 
paresthesia, and neuralgia. 

Hyperesthesia. — The upper portion of the pharynx is liable to 
increased sensitiveness in persons subject to frequently recurring- 
attacks of inflammation, and in the hysterical. Xo other abnormality 
may be discernible in the individual aside from the exquisitely sen- 
sitive throat. 

Treatment. — If any inflammatory condition appear on examina- 
tion, this must be combated by such remedies as have been mentioned 
for pharyngitis, etc. If the condition give considerable discomfort 
one may be justified in applying cocaine or eucaine in a -1-per-cent. 
solution, without the patient's knowledge of the nature of the remedy. 
A 10-per-cent. solution of carbolic acid in glycerin obtunds the sensi- 
bilities of the nerve-ends, and does not present any of the objections 
applicable to cocaine. The membrane can be protected by an emoll- 
ient and slightly anesthetic spray consisting of camphor-menthol 
in lavolin. It is best to begin with a 3-per-cent. solution of this, giv- 
ing the patient directions to use it in an atomizer for home treatment, 
and increase to a 10-per-cent. solution in office treatment, which can 
readily be done if the stronger preparation is employed in the vapor- 
izer or nebulizer (Figs. 131 and 132), at first, and afterward in a 
coarser spray (Fig. 131). 

Aristol is preferable to most other powders, for its local anes- 
thetic and adherent qualities. Aconite in glycerin, a salol- or anti- 
pyrin- spray or guaiacol applications diluted with glycerin at first, 
pure afterward, are indicated if a rheumatic or gouty condition exist. 
Added to these, sodium salicylate, salicin, antipyrin, and lithium are 
effective in ridding the system of the uricacidemia that may lie at the 
root of the trouble. 



436 NEUROSES OE THE PHARYNX. * 

If the case is of an hysterical nature, sedatives and tonics are 
required: valerian, the bromides, strychnia, arsenic, iron, etc. 

Ansesthesia. — Loss of sensation is of less import than its ex- 
altation, since it is not accompanied with like suffering. It is some- 
times a sequel of diphtheria or insanity. Nerve-tonics, such as are 
mentioned above, and galvanization are indicated. 

Paresthesia. — Patients sometimes experience the sensation as if 
some foreign body were in the throat, when it is impossible to make 
out either the presence of one or any evidence that one may have at 
any time found lodgment. Indeed, no abnormal condition what- 
ever of the pharynx is discernible. This condition obtains in hys- 
terical individuals, and it is difficult to satisfy them that they are 
mistaken. This manifestation is purely of a neurotic character and 
must be treated accordingly. 

Treatment. — Such methods as are recommended for hyperes- 
thesia are appropriate here, — nerve-stimulants, tonics, or sedatives, as 
the particular features of the case may demand. 

Neuralgia. — While painful sensations in the pharynx are some- 
times attributable to inflamed follicles, uric-acid irritation and vari- 
ous local lesions, there is a class of cases in which pain is experienced 
without the presence of any visible morbid process to account for it. 
This occurs in hysteria and is very difficult to influence. 

Treatment. — If airy local lesion can be discovered it must be 
treated according to the principles already laid down, but when the 
pain is purely neurotic, topical applications to the sensitive or painful 
spot, if it can be located, and nervines, sedatives, and tonics, as set 
forth in treating of hyperesthesia, must be brought into requisition. 

NEUROSES OF MOTION. 

Two kinds of neuroses of motion are met with: spasms and 
paralysis. 

Spasms. — Spasmodic contractions of the pharyngeal muscles may 
be excited by any local irritant: traumatic, such as harsh particles of 
food; or idiopathic, such as inflamed follicles; or the affection may 
be purely neurotic, such, for example, is globus hystericus. The 
levator palati muscle is occasionally subject to choreic attacks, in 
which the soft palate is thrown against the wall of the pharynx with 
more or less regular contractions and relaxations, accompanied by 
objective smacking or crackling sounds. These spasms may be asso- 
ciated with serious and grave neuroses, as well as with inflammatory 



BURNS AXD SCALDS OF THE PHAEYNX. 437 

conditions of the soft palate. Central nervous lesions and hydropho- 
bia are characterized by this symptom. 

Treatment. — It' pharyngeal spasm can be traced to inflammation 
of the velum or oedema of the uvula, the proper treatment already 
outlined for these conditions will afford relief. Anomalous condi- 
tions of the nasal cavity must be searched for, and inflamed follicles 
in the pharynx that might provoke the attacks. Any local diseased 
condition must be corrected. When the contractions are dependent 
upon other maladies the treatment must naturally be addressed to the 
initial affection, such as brain-tumors and hydrophobia, for the spasms 
constitute a symptom only of such diseases. Diffusive nerve-stimu- 
lants, tonics, and hygienic and dietetic measures appropriate to each 
case will be suggested by the conditions present. 

Paralysis of the Pharynx. — Paralysis of the muscles of the 
pharynx results from diphtheria, syphilis, some central nervous lesion, 
or the fatal fevers. All the pharyngeal constrictor muscles may be 
involved or the disease may affect only one, or the muscles of one 
side alone are sometimes involved. There may be paralysis of one- 
half and paresis only of the opposite half of the pharynx. 

Swallowing and speech are more or less impaired, according to 
the extent of the paralysis. Food, and especially liquids, regurgitate 
into the posterior nares or enter the larynx. The latter accident is 
the more likely to occur when the epiglottis is included in the par- 
alytic condition. 

Treatment. — The therapeutic measures will be determined by 
the nature of the lesion on which the paralysis depends. If it is 
a sequel of diphtheria, strychnia and arsenic are indicated. Ex- 
cellent results have been reported from the subcutaneous injections 
of strychnine. In addition to tonics I prefer for such conditions a 
current from the primary coil of a faradic battery, which, as the gal- 
vanometer demonstrates, possesses galvanic properties. This will 
cause contractions of the muscles if the disease lias its origin in the 
nervous centres, but in case of atrophy of the muscles they do not 
respond to the current. The condition in the latter case is unpromis- 
ing. In addition to electric treatment three or four times a week, 
general tonic remedies are usually called for. 

Beexs axd Scalds of the Phaeyxx. 

The pharynx is the seat of injury from inhaling very hot steam, 
air. or smoke, especially in burning buildings. Firemen are particu- 



438 FOREIGN BODIES IN THE PHARYNX. 

larly subject to these accidents. Children sometimes inhale steam 
from a tea-pot or tea-kettle or pour hot liquids down their throats. 
Patients and nurses by mistake give escharotic fluids instead of the 
correct internal medicine. I have had patients whose throats were 
severely burned by aqua ammonia and carbolic acid in strong solu- 
tions that were administered by mistake from bottles standing be- 
side those containing the proper remedies. 

Symptomatology. — Immediately after these accidents the mu- 
cous membrane of the throat is of a gray color, produced by the de- 
structive agent. Inflammation follows, with more or less suppura- 
tion and sloughing of the tissues. 

Diagnosis. — This is usually made by the patient or his friends 
before the arrival of the physician. 

Prognosis. — Firemen and persons caught in burning buildings 
are often so seriously burned by inhaling heat, hot smoke, and steam 
that recovery is impossible. There may be such an extensive break- 
ing down of the tissues in the throat as to leave a stenosis if recovery 
take place. 

Treatment. — Ice-bags (Fig. S3), cool drinks, or pellets of pure 
ice in the mouth afford some relief and tend to modify the severity 
of the inflammation. Nourishment may have to be given for a time 
per rectum. When the larynx is involved to the extent of impending 
suffocation, tracheotomy must be performed at once. 

Foreign Bodies in the Pharynx. 

It is not uncommon to find, fish-bones, pins, needles, and bristles, 
among sharp-pointed articles, lodged in the walls of the pharynx. 
As the constrictor muscles contract about them, they are forced into 
the soft tissues, until in some instances they escape detection on first 
looking into the throat. I have found such bodies as sections of 
juniper-leaves, etc., so imbedded as to be extracted with the greatest 
difficulty. This is especially true when they have remained for a 
number of days in the throat exciting continued efforts at swallowing 
and setting up an intense congestion and swelling of all the sur- 
rounding structures. 

Besides articles of a sharp, piercing nature that penetrate the 
tissues, bodies like unmasticatecl boluses of food and coins occasionally 
slip into the gullet and threaten strangulation. 

Symptomatology.— Sharp bodies are generally arrested in their 
progress by being caught in the lateral walls of the pharynx, where 



TREATMENT OF FOREIGN BODIES IN THE PHARYNX. 439 

they will be found projecting from the tissues which they have pene- 
trated. Small bodies are likely to lodge on one side of the epiglottis 
in the pyriform sinus. The large boluses of food, coins, etc., are 
arrested at a point just posterior to the larynx or a little superior to 
it, and are very liable to catch upon the epiglottis and force it down- 
ward. Little bodies often drop into the pyriform sinus or the glosso- 
epiglottic fossa. 

The symptoms produced by foreign bodies in the throat are 
sometimes very distressing, and even dangerous. If the epiglottis is 
forced downward so as to close the entrance to the larynx the patient 
may suffocate before relief arrives. When sharp articles stick in the 
throat they produce a pricking sensation, which increases during the 
act of swallowing. Pebbles, buttons, and the like may remain secreted 




Fig. 199. — Mackenzie's lateral throat-forceps. 

in the pyriform sinuses for a considerable time without giving rise to 
serious inconvenience. 

It often happens that when crusts of bread and other hard sub- 
stances are swallowed they scratch the mucous membrane of the 
throat, and this abrasion, giving rise to irritation, produces the im- 
pression in the mind of the patient that a foreign body is present. I 
have known them to insist strenuously upon the presence of some 
substance; but an application of a 4-per-cent. solution of cocaine to 
the irritated area removed it apparently. There is also a similar sen- 
sation due to a point of irritation which may be found to exist in 
an inflamed follicle. 

Certain susceptible persons occasionally believe they are afflicted 
with a foreign substance in the throat when the trouble is purely a 
nervous one, — globus hystericus. 

Treatment. — Sometimes foreign bodies can be seen by depressing 
the tongue, but generally the laryngeal mirror is necessary. Eemem- 



440 TREATMENT OF FOREIGN BODIES IN THE PHARYNX. 

bering what has been said about the points of lodgment of the various 
kinds of bodies, and ascertaining, if possible, from the patient what 
the object was most likely to have been, the search is much facilitated. 
Sometimes it is best to insert the finger to locate the body, and it may 
be possible to extract it during this examination. 

Long, curved forceps are best adapted to this use (Fig. 199). One 
should be careful to not wound the adjacent tissues in the effort to 
grasp the foreign body. 

In extreme cases it may become necessary to open the trachea 
in order that respiration may proceed until the body can be rescued. 
A bolus of food may be forced down into the oesophagus if it cannot 
be extracted. Considerable irritation or inflammation follows these 
accidents. 



PART IV. 



Diseases of the Larynx 



(441) 



PLATE VI. 



PLATE VI. 



ANATOMY OF THE LARYNX. 



Figs. 1 to 9. 



a, Thyroid cartilage. 

b, Cricoid cartilage. 

c, Arytenoid cartilage. 

d, Cartilage of Santo rini. 

e, Cricothyroid membrane. 
/, Vocal band. 

g, Arytenoidens muscle. 

h, Lateral cricoarytenoid muscle. 

i, Posterior cricoarytenoid muscle. 

j, Epiglottis. 

k, Vocal process. 



m, Cartilage of Wrisberg. 

n, Aryteno-epiglottic fold. 

o 1 , Upper fasciculus of thyro-arytenoid muscle. 

o Q , Middle fasciculus of thyro-arytenoid muscle. 

o 3 , Lower fasciculus of thyro-arytenoid muscle. 

p, Ventricle of the larynx. 

q. Laryngeal sac. 

r, Ventricular band. 

s, Superior aryteno-epiglottic muscle. 

t, t*. Two fasciculi of thyrocricoid muscle. 

u, Superior thyro-arytenoid ligament. 



Fig. 1. 
posterior view. 
Vocal bands abducted by 
contraction of posterior crico- 
arytenoids (arytenoidens cut 
off). 

Fig. 4. 



ABDUCTION AND ADDUCTION. 

Fig. 2. 
lateral view. 
Section of larynx showing 
the relation of adductor and 
abductor muscles. 



Fig. 3. 
posterior view. 
Vocal bands adducted par- 
tially by contraction of lateral 
cricoarytenoids (arytenoi- 
deus not having acted)" 

Fig. 5. 



HORIZONTAL SECTION OF LARYNGEAL FRAME-WORK, ABOVE VOCAL BANDS. 

Vocal bands in abduction. Vocal bands in partial adduction. 



EXTENSION AND RELAXATION. 



Fig. 6. 
lateral section. 
Relaxation of vocal band 
through contraction of thyro- 
arytenoids and relaxation of 
thyrocricoids. 



Fig. 7. 

lateral section. 

Interior of larynx. Flaps 

raised to show laryngeal sac, 

and the relation of muscles 

with the mucous membrane. 

Fig. 9. 
anterior section. 
Interior of larynx and rela- 
tion of muscles. 



Fig. 8. 
lateral section. 



Extension of vocal band by 
elevation of the cricoid carti- 
lage through contraction of 
the thyrocricoid muscles and 
relaxation of the thyroaryt- 
enoids. 



Fig. 10. 

innervation of the larynx. 

Posterior section of neck and upper part of chest, showing 

the course of the pneumogastric nerves, their branches, and 

their relations. Lateral half of trachea and quarter of larynx 

cut off. 



A, A 1 . Pneumogastric nerve. 

B, B l , Superior laryngeal. 

C, Right recurrent laryngeal. 

D, Right lung. 

E, Left recurrent laryngeal. 

F, Branch of superior laryn- 

geal. 

a, CE-ophagus. 

b. Aorta. 

e. Pulmonary artery. 
d, Trachea. 

e (upper). Internal jugular 
vein cut off. 

(lower), Bronchi. 

Arytenoid caitilaga. 

Subclavian artery. 

Commrm carotid artery. 

External carotid artery. 

Internal carotid artery. 

Base of cranium. 

(upper*. First cervical 
vertebra. 

(lower). Arytenoidens 

muscle. 

Pharynx cut off from up- 
per attachments. 

Epiglottis. 

Hyoid bone. 

Thyroid cartilage. 

Cricoid cartilage. 



s, Thyroid gland. 
u, Thyrocricoid muscle. 
v, Cervical vertebrae. 
x, y. Muscles of neck. 
2, Innominate artery. 



Fig. 11. 
arteries and" veins of 
the anterior portion 
of the neck. 

Vessels of the neck, show- 
ing those in danger of being 
severed in making artificial 
opening into the larynx and 
trachea, and their connec- 
tions. 



Trachea. 
Cricoid cartilage. 
Thyroid cartilage. 
Thyroid gland." 
Cricothyroid membrane. 
Thyrohyoid membrane. 
Hyoid bone. 
Aorta. 

Innominate artery. 
Common carotid artery. 
Superior thyroid artery. 
Anterior jugular vein. 
Cricothyroid artery. 
Internal jugular vein. 
Thvroid plexus. 
Right inferior jugular 

vein. 
Left inferior jugular vein. 
Cricothyroid vein. 
Superior thyroid vein. 
Middle thyroid vein. 
External jugular vein. 
Subclavian vein. 
Right and left innominate 

vein. 
Superior vena cava. 



PLATE VI 




"« ■- H.rZT? 



CHAPTER XXXVI. 

DISEASES OF THE LARYNX. 

INDIRECT LARYNGOSCOPY AND INSTRUMENTS. 

Examination of the interior of the larynx, commonly called 
laryngoscopy, is made by means of a light reflected into the larynx 
through the medium of two mirrors. The first, or forehead-, mirror 
is illustrated in Fig. 4, and is used in the same manner as in otoscopy 
and rhinoscopy, already described. The second mirror, sometimes 
dignified by the name of laryngoscope, consists of a circular plane- 
glass mirror inclosed in a metallic frame, to which is attached a wire 
handle set at an angle of 120 degrees to the plane of the mirror 
(Fig. 123). It is made in several sizes, but those most commonly 
employed vary from one inch (twenty-five millimetres) to one-half 
inch (twelve millimetres) in diameter. The most perfect view is 
obtained by using as large a mirror as the proportions of the throat 
will permit without contact between mirror and mucous membrane. 
The sizes are numbered according to their diameters, No. 1 being 
one inch (twenty-five millimetres) wide, and the others graded by 
one-eighth-inch (three millimetres) variations down to one-half inch 
(twelve millimetres), and numbered accordingly. In the capacious 
throats of adults the largest size is to be used, while in children the 
smaller ones are necessary. 

For the purposes of illumination there are various devices for 
projecting the rays of light upon the laryngeal mirror. Fig. 200 shows 
an ingenious device of Allen De Yilbiss, which is a modification of 
Mackenzie's light-concentrator. It is simpler in construction than 
Tobold's apparatus, although it is similar to it. It is provided with 
two mirrors, one plane and the other concave, both of which are at- 
tached to a stationary mirror-bar by means of ball-and-socket joints, 
so arranged that they may be easily changed to any position on the 
bar and inclined at any angle. 

The plane mirror enables the physician to show his patient the 
condition of the affected parts, and, if needing treatment, illustrate 
its necessity. "By this method patients may see the extent and 
nature of their diseases and receive treatment when they might other- 

(443) 



444 



INDIRECT LARYNGOSCOPY. 



wise consider it of but little importance, not demanding medical as- 
sistance." If deemed advisable, the patient may be shown, from time 
to time, the changing condition of his disease, and thus be kept in- 
terested in its treatment. By this device the patient can see to keep 
himself u in light," thus relieving the physician from the necessity 
of frequently adjusting the mirror. This laryngoscope can be ad- 
justed to a student's lamp, and may be raised or lowered by means 
of a single set-screw. Figs. 1, 2, and 5 show other adjustable lamps. 
Assuming that we have proper illumination, the examination 




Fig. 200. — De Vilbiss illuminator 



proceeds as follows: The patient and examiner being in the relative 
positions illustrated in Fig. 200, with the patient's mouth open, the 
tip of his tongue is taken between the physician's thumb and index 
finger, protected from actual contact with the tongue by a napkin or 
thin towel, and the tongue is held protruded from the mouth. The 
patient should not make an effort to force the tongue forward nor 
to retract it, but should let it lie passively in the surgeon's control. 
This is necessary in order to raise the epiglottis and expose the apert- 
ure of the larynx. This is effected by traction on the glosso-epiglottic 
ligament, which happens in the drawing forward of the tongue. Un- 



INDIRECT LARYNGOSCOPY. 445 

less the examiner is careful in this act he will wound the frsenum on 
the sharp edges of the lower incisor teeth. It is advantageous to 
instruct the patient to assist in his examination by holding his tongue 
himself, using the hand opposite to the one used by the examiner, so 
as not to be in the way of the laryngeal mirror as it is introduced. 

The light is now focused on the uvula, and the front of the 
laryngeal mirror is exposed for only an instant over a flame to warm 
it. This must be done in order to prevent the moisture of the breath 
from condensing upon the glass and blurring the laryngeal image. 
After a second of warming the mirror it is touched to the surgeon's 
cheek, or a sensitive part of his hand, to determine if the heat is 
sufficient to avoid condensation. If the flame is very hot, or if the 
mirror is exposed to it during too long an interval, the silver, or 
other backing of the glass, is fused, and the instrument destroyed. 
Glass being a poor conductor of heat, there is less danger of melting 
the coating of the back if the glass itself is held next the source of 
heat. 

The laryngeal mirror now being ready for introduction, it is 
held like a pencil, and without loss of time, which would allow the 
mirror to cool, it is carried into the throat in such a way as to avoid 
contact with the tongue and surrounding parts, so as not to cause 
nausea and retching. The back of the mirror is made to impinge 
upon the anterior surface of the uvula and to carry the latter upward 
and backward. The mirror is then turned so as to reflect the rays 
of light from the forehead-mirror into the cavity of the larynx, when 
an image of the interior of the larynx and the superior portion of 
the trachea will come into view. The patient should be told that no 
pain will be caused, and that he should remain perfectly passive and 
breathe quietly. If he is able to accommodate himself to the situa- 
tion, an opportunity is given to study the vocal cords, which are 
seen in an abducted relation, of a white color, about three-fourths of 
an inch (two centimetres) long, and diverging from the upper to the 
lower ends, as seen in the reflected image (Plates II and V). 

If the subject is caused to utter the broad, open sound repre- 
sented by the syllable "ah," as used by vocalists in developing their 
voices, the vocal bands approximate each other and become parallel, 
with only a narrow slit preventing contact between them. As seen 
before vocalization, the vocal bands are concealed largely from view- 
by the ventricular bands, only their borders being then visible. 

One should not forget that he is not looking directly at the eon- 



446 DIFFICULTIES OF LARYNGOSCOPY. 

tents of the larynx, but at an image of them in a mirror, which, of 
course, reverses the picture to the observer; or, in other words, the 
examiner sees the picture as he would if his eye were behind and 
above the larynx, — the position occupied by the mirror. The epiglottis 
appears in the upper section of the mirror as a yellowish-pink valve, 
showing on its surface a map of minute blood-vessels. Its outline is 
suggestive of a Cupid's bow, with the convex surface directed upward. 
Just below this bow is seen the anterior commissure of the vocal 
cords, which is narrower than the posterior commissure, as shown 
in the lower part of the image. The right vocal band appears in 
the left field of the image and the left is reflected in the right side 
of the picture. From the right and left termini of the bow-shaped 
borders of the epiglottis spring the aryepiglottic folds, curving grace- 
fully inward to meet each other in the form of a horeshoe, and com- 
pleting the superior boundary of the opening into the larynx by their 
union in the arytenoid commissure (Plate VII). On either side of 
the junction of the aryepiglottic folds is a nodular eminence called 
the cartilage of Santorini, and immediately to the outside of these 
knobs, on either side and slightly elevated above them, is a bulbous- 
appearing prominence, — the cartilage of Wrisberg. These eminences 
are of a redder hue than the epiglottis. Below them are seen the 
ventricular bands, which spring from an area corresponding to the 
junction of the cartilages of Santorini and Wrisberg (Plate V, Xo. 9). 
The junction of the ventricular bands in front, their anterior 
commissure, is concealed by an eminence, — the cushion of the epi- 
glottis. The vocal bands or cords appear below the ventricular 
bands, extending from below the cushion of the epiglottis to points 
just inferior to the cartilages of Santorini. Between the ventricular 
band and vocal cord is a dark aperture termed the ventricle of the 
larynx. Beyond all these structures appear the rings of the trachea. 
From three to six are usually in sight, and sometimes a view of the 
whole length of the trachea to the branch of the right bronchus is 
obtained. For the anatomy of the larynx see Plate VI. The various 
images resulting from correct and incorrect methods of examination 
are illustrated in Plate VII. 

Difficulties of Laryngoscopy. 

Laryngoscopy examinations are not without considerable ob- 
stacles in many instances. Although there are individuals with 
capacious throats devoid of sensitiveness, who readily co-operate so 



DIRECT LARYNGOSCOPY. 44 T 

as to afford a broad-gauge view of the interior of the larynx and 
trachea, there are frequently persons who have little or no control 
of their muscles, and who retch and gag, and even vomit, when an 
attempt is made at laryngoscopy. In such cases it may become 
necessary to inure the throat to the presence of foreign bodies by 
the practice, on the part of the patient, of inserting smooth, blunt 
articles, such as spoon-handles and the like, daily at home. In this 
manner a tolerance of instruments may be cultivated to such a degree 
as to render successful subsequent attempts at an examination. 

"When repeated efforts fail on account of hypersensitiveness of 
the throat, it is necessary to bring to our aid a 4-per-cent. solution of 
cocaine or eucaine. This is painted over the base of the tongue and 
the soft palate, and in a few minutes the sensibilities of the nerves 
are so benumbed as to permit of a thorough inspection with the 
mirror. 

Another instance in which it may become necessary to employ 
a local anaesthetic is when the epiglottis is pendent to the degree of 
obstructing the rays of light and preventing their penetrating the 
laryngeal cavity. In this condition the epiglottis must be raised and 
pressed forward out of the field of vision by a curved probe; but, 
in order to do so without producing pain and gagging, the epiglottis 
must be treated to the cocaine solution. 

The tongue is often forced upward and shuts off the view if the 
mirror come in contact with it and produce gagging. The patient 
is told not to strain, and the tongue is not drawn forcibly forward. 
If then the arching of the tongue does not recede, the tongue-de- 
pressor must be employed. If the mirror is held by the right hand, 
the tongue-depressor is held by the left in such a way that the in- 
strument intervenes between the thumb and the tongue, and the first 
finger rests under the tip of the tongue. The depressor must not be 
carried far enough backward to provoke nausea and retching. 

"When the tonsils are enlarged they so encroach upon the lumen 
of the cavity as to interfere with a satisfactory laryngoscopy. A small 
mirror must be resorted to: but tonsils sufficiently hypertrophied to 
embarrass an examination of the larynx ought to be clipped. 

Direct Laryngoscopy. 

Max Thorner has recently called the attention of laryngologists 
to a method of examining the larynx and trachea without the laryngo- 
scopy mirror. In a paper on this subject in The Laryngoscope for 



448 



DIRECT LARYNGOSCOPY. 



February, 1897, and in a translation of a monograph by Alfred Kir- 
stein, of Berlin, on "Antoscopy of the Larynx and Trachea," 1897, 




Fig. 201. — Position for antoscopy. This photograph was taken from a partly 

stripped patient in order to show distinctly the position of head 

and neck during examination. (Thorner.) 

the method and instruments are described and illustrated in detail. 
The method consists essentially in pressing the tongue forward 




Fig. 202.— Tongue-depressor for pharyngoscopy and direct laryngo- 
tracheoscopy. Side-view and surface- view of the anterior portion. In some 
cases an instrument Avith a larger curve of the anterior portion is more 
practicable. ( Thorner. ) 



and downward until the axis of the laryngo-tracheal tube and that 
of the buccal cavity coincide with each other. This is effected, first. 



DIEECT LARYNGOSCOPY. 



449 



by having the patient incline the upper part of his body a little 
forward, and the face slightly upward, with his mouth open (Fig. 
201). The garments about the neck should be loose, and if false 
teeth are worn they must be removed before the introduction of the 
specially-constructed spatula or the electroscope. Second, the phy- 
sician, standing before the patient, passes the spatula, baring a down- 
ward curve at the inserted extremity (Fig. 202) behind the circum- 
vallate papillae, and downward to the root of the tongue. The epi- 
glottis is then elevated by the method described in 1879 by Reichert: 
"Pressure upon the base of the tongue and the median glosso-epi- 




Tangential plane. iThorner.) 



glottic ligament produces an elevation of the epiglottis on account 
of its close attachment to the tongue.'* 

So, with the patient in the position described, and the spatula 
introduced, the tongue is pressed downward and forward, the epi- 
glottis at the same time is brought upward and forward until a 
straight line in the groove of the autoscope coincides with the longi- 
tudinal axis of the laryngotracheal canal (Fig. 203). This brings 
the cavity of the larynx and the trachea to the bronchial bifurcation 
into direct view. The posterior wall of the larynx is easily inspected, 
but the anterior commissure, the ventricles of Morgagni. and the 
pyriform sinuses are not within range of vision, and must be left for 
examination with the laryngoscopic mirror. 



450 



DIRECT LARYNGOSCOPY. 



A prerequisite to successful "autoscopy" is that the rays of light 
be projected from the forehead into the throat, preferably by the 
electric head-light or by the electroscope (Fig. 204). The latter is 
a modification of Casper's instrument for inspecting the urethra. It 
has a handle containing an electric lamp, and a lens which focuses 
the light upon a prism, which, in turn, deflects the rays 90 degrees. 
The light is reflected in this manner along the spatula of the elec- 
troscope into the laryngeal cavity. The examiner looks over the 
prism and sees the contents of the larynx and trachea directly, just 
as he sees the nasal cavities in anterior rhinoscopy. 




Fig. 204. — Standard spatulas (#), attached to the electroscope, and intra- 
laryngeal spatula ($')> both with hoods omitted. (Thorner.) 



While it is not claimed by Thorner or Kirstein that this method 
should supplant the use of the laryngoscopic mirror, they assert for it 
certain advantages, which may be summarized as follow: Direct 
laryngoscopy gives a more realistic view of the organs inspected, in 
regard to both the normal color and the absence of reversal of the 
picture, both of which are important considerations in operative 
procedures; the posterior wall of the larynx and the deep portion, 
of the trachea are subject to inspection; operations on the larynx 
and trachea are performed with greater exactness and facility under 
direct linear inspection. 



DIRECT LARYXGOSCOPY 



451 



Thorner regards this method of direct laryngoscopy "the most 
important addition to our technical resources since the discovery of 
the laryngoscope by Garcia. " It is evident that the obliteration of 
the obtuse angle formed by the intersecting axes of the buccal cavity 
and the laryngotracheal tube, by rendering these axes coincident, 
calls for instruments without the curve that characterizes those com- 
monly employed. Operations by the new method require that in- 
struments be constructed after the types shown in Fig. 205. 




Fig. 205. — Types of instruments for autoscopic operations. (Thorner.) 



Inspection with the autoscope — an unfortunate choice of name, 
since it is likely to be confounded with the word otoscope in speak- 
ing — necessitates monocular vision. About 50 per cent, of patients 
cannot be examined by this method. It requires considerable self- 
possession on the part of the patient as well as much practice on the 
part of the surgeon. Both Ivirstein and Thorner concede that it 
should supplement, but not supplant, the use of the laryngoscopic 
mirror. 



CHAPTER XXXVII. 
DISEASES OF THE LARYNX, CONTINUED. 

Acute Laryngitis. 

Synonyms. — Acute catarrh of the larynx; spurious cronp. 

Pathology. — Acute inflammation of the mucous membrane lining 
the laryngeal cavity (Plate VII) is characterized by an engorgement 
of the blood-vessels, — an hyperemia, — accompanied, at first, by dry- 
ness of the membrane and afterward by an exudation of serum upon 
the mucosa, mixed with undeveloped epithelial cells and white cor- 
puscles. The thin, translucent secretion soon gives place to a more 
copious secretion of a thick, opalescent, mucoid character, studded 
with desquamated epithelium, pus-corpuscles, and traces of blood. 
Points of denudation of the mucous membrane are generally present, 
but the submucosa is rarely invaded by ulceration in this affection. 

Etiology. — Exposure to cold is the most common cause of this 
inflammation. Sudden changes from warm, ill-ventilated apartments 
to a cold, damp, or windy atmosphere when the subject is in a per- 
spiration or insufficiently clad are frequently followed by laryngitis. 
This is most commonly seen during the changes of the seasons from 
fall to winter and from winter to spring. The inhalation of irritating 
gases such as are often generated in laboratories may excite a catarrhal 
condition of the larynx. Dust of certain kinds is a causative factor. 
Persons riding over the alkali deserts or plains of the western part of 
the United States are sufferers from rhinitis, laryngitis, and con- 
junctivitis, occasioned by the irritating effects of the great quantities 
of alkali-dust in those regions. Overtaxing the voice and its improper 
use by singers and speakers induce attacks of acute laryngitis. In- 
stances of this affection are very common during political campaigns, 
when stump-speakers are driven from the field by the inordinate use 
of their vocal organs. Firemen — who shout in the heat and smoke 
of burning buildings, and who often inhale much of the hot air, 
steam, and smoke — are subject to this disease. The uric-acid diathe- 
sis, rheumatic and gouty conditions, and the eruptive diseases stand 
in a causative relation to acute laryngitis. 

Symptomatology. — The premonitory symptoms of acute laryn- 

(452) 



ACUTE LARYNGITIS. 453 

gitis may be so vague and trivial as to scarcely arrest the attention 
of the subject. A slight feeling of dryness, as though the air inhaled 
were devoid of moisture, and, therefore, irritating, is generally the 
first unusual condition noticed. This is likely to be followed by a 
scratching or tickling sensation that excites efforts to relieve it by 
clearing the throat or coughing, which, instead of relieving the irri- 
tation, only adds to the feeling of roughness. A sense of constriction 
or of soreness soon follows, but palpation of the larynx seldom de- 
velops tenderness, except in rheumatic attacks. As the disease pro- 
gresses and the vocal cords become involved, the voice changes in 
quality, or timbre. It takes on a rough, husky, or hoarse, character, 
which has the effect of apparently lowering its pitch. 

About this time discomfort in swallowing occurs, amounting to 
a very painful effort. This is especially the case in the rheumatic 
form of the disease, and with the accentuated painfullness of degluti- 
tion may come a complete loss of voice, so that the only speech pos- 
sible to the patient is a forced whisper. Cough is not necessarily 
a symptom of acute laryngitis, but is frequently present. Its hoarse 
character is indicative of the location of the causative lesion in the 
larynx. Auscultation of the larynx will demonstrate the presence of 
mucous rales. These are not heard during the initiatory stage, in 
which the mucous membrane is dryer than it is in the normal state; 
but later, as the serous exudate and mucus bathe the walls of the 
larynx, the passing of air through these fluids gives rise to easily- 
detected rales. The expectoration is characterized by the presence 
of the secretions just mentioned, and later in the disease by the pres- 
ence of pus, possibly streaked with blood. The presence of blood, 
however, is generally an accidental and unusual feature, being the 
result of a very violent fit of coughing or, perhaps, of vomiting. 

Acute laryngitis does not usually give rise to very serious gen- 
eral disturbances of the system in adults, but it often presents alarm- 
ing symptoms in children. As all diseases produce a more profound 
impression during the early years of life than in adults, so acute 
laryngitis may evoke such violent symptoms as to fill the patient 
and friends with terror. The temperature rises; the pulse becomes 
accelerated, bounding, and hard, and the tongue is heavily coated. 
Even when the little patient appears during the day to have no 
serious sickness, he may awaken at night with a suffocative attack out 
of all proportion to the apparent cause. The respiration is embar- 
rassed and the respiratory effort is marked by an audible, stridulous 



454 ACUTE LAKYXGITIS. 

sound. The cough reveals a changed voice, hoarse and husky, and 
the diminished oxygenation of the blood and the frantic efforts to 
overcome the obstruction to breathing bring on a swollen and con- 
gested appearance of the face. 

These attacks are sometimes called stridulous laryngitis, and they 
are probably occasioned by the drying of accumulated discharges in 
the glottis. The child breathes through his open mouth, with the 
result that the air entering the larynx and lungs is not moistened by 
the secretions of the nose, as it is in normal respiration. Conse- 
quently the dry air causes rapid evaporation of the water of the 
laryngeal secretions, with the effect of causing them to dry upon the 
vocal cords until they offer a positive obstacle to the current of in- 
spired air. When the obstruction has existed long enough to cause 
actual distress the patient awakens in a frightful state of impending 
strangulation. Soon, however, the active efforts of the patient to 
dislodge the inspissated secretions relieve the stenosis and restore free 
respiration, when calm succeeds the storm. 

The attacks described here have been attributed by some authors 
to a spasm of the adductors of the vocal bands. This spasmodic con- 
traction may play a role as a complication, but the mechanical ex- 
planation is reasonable; all the elements requisite to the production 
of such attacks are present; and it so conforms to our experience with 
similar conditions in other situations as not to necessitate an exercise 
of the imagination to account for all the phenomena observed. 

Inspection of the larynx during an attack of acute inflammation 
reveals a mucous lining of a bright-red color (Plate VII). The con- 
gested condition may be limited to various portions of the membrane, 
but usually it is diffused over the whole surface. There is a tumefied 
condition in severe forms of inflammation, and the ventricular bands 
may be so swollen as to override the true vocal bands and nearly 
occlude them from view. Then they are seen as slight, reddened 
lines below the ventricular bands. Ulcerations are not frequently 
seen, but small spots of the membrane denuded of its epithelium may 
be present. The epiglottis may participate in the inflammation, as 
shown in Plate VII, or it may not be involved. 

(Edema occurring in the course of laryngitis constitutes a grave 
complication, since it may give rise to fatal stenosis (Plate VII). 

Diagnosis.- — In adults no serious difficulty to a diagnosis presents, 
in view of all the symptoms related. It is not likely to be confounded 
with diphtheria except in children, when it may be mistaken for 



TREATMENT OF ACUTE LARYNGITIS. 455 

true croup. In ease of doubt, an examination of the fauces will likely 
reveal false membrane if diphtheria is present. A laryngoscopic ex- 
amination should be had if obtainable. The secretions should be 
subjected to bacteriological examinations if there is reason to suspect 
diphtheria. However, this disease does not run such a course as does 
diphtheria and it is not attended with the symptoms of profound 
sickness comparable to those of diphtheria. 

Prognosis. — This disease is of short duration and yields readily 
to proper treatment. 

Treatment. — Local remedies are useful as detergents, astrin- 
gents, anaesthetics, protectives, and tonics. A spray of a mild alkaline 
solution with antiseptic properties, such as Dobell's, will dissolve 
and wash away the discharges, and. besides leaving the mucous mem- 
brane clear and free for the application of other medicaments, the 
effect is a very agreeable and soothing one. In the dry stage the 
author has found menthol very efficient when inhaled in several dif- 
ferent ways. If no atomizer is at hand, the crystals can be fused in 
a teaspoon over a lamp or stove until the atmosphere of a small room 
is comfortably impregnated with the volatile fumes. The patient is 
directed to keep his eyes closed to prevent any smarting, and. unless 
his nostrils participate in the inflammation, he is instructed to breathe 
through the mouth. The inhalation starts a refreshing flow of mu- 
cus to bathe the parched membrane of the dry stage. Another ex- 
cellent treatment consists in putting 10 drops of pure camphor-men- 
thol into a half-pint of hot water contained in a hot-water inhaler 
(Fig. 140) or in a tea-pot or kettle, wrapping a napkin around the 
nozzle to prevent burning the lips, and then inhaling this medicated 
steam through the mouth with the lips embracing the nozzle. The 
hot, moist steam has an excellent effect, in addition to the action of 
the camphor-menthol, in contracting the capillary blood-vessels and 
producing a slightly anaesthetic and antiseptic effect. 

Cocaine and silver nitrate are recommended by some writers and 
are used much oftener than they ought to be. They are to be avoided 
in acute laryngitis. 

The writer has found his throat tablets useful, and they can be 
given freely, without producing any unpleasant consequence-, except, 
perhaps, nausea. Each tablet contains 1 grain of ammonium chlo- 
ride and the equivalents of 5 minims each of paregoric, compound 
syrup of squills, and syrup of Tolu, with 3 grains of extract of licorice. 
These are held in the mouth and allowed to dissolve slowlv and trickle 



456 TREATMENT OF ACUTE LARYNGITIS. 

down the throat. Besides the desirable action of the ingredients of 
this tablet on the mucous membrane of the throat, the licorice gen- 
erally produces a laxative effect on the bowels. J. D. Arnold recom- 
mends, in the case of superficial erosions, the use of cocaine, followed 
by painting the laryngeal mucous membrane with a 1- or 2-per-cent. 
solution of chromic acid. He employs the cocaine not for the purpose 
of anaesthesia, for this strength of chromic-acid solution is not pain- 
ful, but to contract and deplete the blood-vessels, in which condition 
the action of the acid is more beneficial. 

If the inflammation is of a severe grade, the ice-bag (Fig. 83) is 
indicated. Leeches to the neck are sometimes employed, but cold is 
preferable. Counter-irritation by mustard, tincture of iodine, aqua- 
ammonia, chloroform, etc., is useful. 

General treatment consists, first, in putting the patient in such 
a condition as is favorable to successful treatment. He need not 
necessarily be put to bed, but he had best remain in-doors for a few 
days, where the temperature is uniform and where he will not be ex- 
posed to those conditions that brought on the attack. In the dry, 
or first, stage, 1 / 6 or even 1 / 3 grain of pilocarpine is useful to stimu- 
late the sudoriferous and salivary glands to activity. This is a sub- 
stitute for the old-fashioned, dismal sweats that loom up in our 
memory of boyhood. Quinine — that much-abused remedy, given for 
almost every ill that afflicts our race — is of little or no use here, as 
far as my experience goes. One or two doses of morphia, 1 / 12 grain, 
combined with atropia, 1 / 600 grain, and caffeine, 1 / 6 grain, have often 
appeared to greatly ameliorate, and even shorten, the attacks ma- 
terially. Irritants — tobacco-smoke, alcoholic liquors, etc.— must be 
forbidden. 

If oedema, be found, the tissues affected must be scarified, to 
let out the contents. Should the tumefaction and stenosis be so great 
as to seriously embarrass respiration or threaten suffocation, trache- 
otomy must be performed. 

The rheumatic type of acute laryngitis is attended with con- 
siderable pain and difficult deglutition, that require promptly-acting 
remedies. Ten-grain doses of salicylate of sodium every two hours 
should be given until either the symptoms begin to show signs of 
relief or the physiological action of the drug begins to manifest itself 
in stuffiness in the ears, diminished hearing, ringing noises in the 
ears, or gastric disturbances. Then the doses should be placed at 
greater intervals or discontinued until these transitory symptoms 



TBEATAIEXT OF ACUTE LAEYXGITIS. 457 

abate, and renewed again in smaller doses until after complete re- 
covery. A fresh preparation should always be made, like the formula 
given in the article on the treatment of rheumatic pharyngitis (page 
343). If the sodium salicylate disagree with the stomach or produce 
serious aural symptoms, and more especially if the patient already 
has an affection of the ear, salicin should be substituted for the salicy- 
late. I hare seen 10 grains of salicin, taken every two hours, produce 
prompt relief before the expiration of a day. This effect is hastened 
if the same doses of effervescing citrate of lithia are taken three or four 
times a day. Antipyrin is often very beneficial in this disease, and 
the same may be said of salophen and salol. 

Climate has a definite effect on the rheumatic form of laryngitis. 
I have known a patient suffering from it during a season of cold, 
humid, windy weather that prevailed along the Great Lakes Eegion, 
to go south, into a genial, warm, sunshiny climate, and recover from 
the attack, without medicine, after two days of life in the sunshine, 
so masic in their effects are climatic conditions. 



CHAPTER XXXVIII. 

DISEASES OF THE LARYNX, CONTINUED. 

Ceoup. 

Synonyms. — Pseudomembranous croup; idiopathic membranous 
croup. 

Pathology. — The question of the identity or duality of croup 
and laryngeal diphtheria is still a mooted one. Excellent authorities 
differ on this subject. So scholarly an author as Sir Morell Mac- 
kenzie believed the two to be identical. Both diseases affect the mu- 
cous membrane, with the result of producing a false membrane. Both 
diseases attack the same organ, — i.e., the larynx. Both obstruct res- 
piration. In these three particulars there is a close similarity in the 
two diseases, but the author is not prepared to admit their identity. 
Croup is primarily an affection of the larynx; diphtheria is generally 
at first an affection of the pharynx, although it may, in a certain 
percentage of cases, develop primarily in the larynx. "In one hun- 
dred and fifty-one diphtheric cases the membrane was limited to the 
larynx only once. In eighty-eight the membrane appeared first in 
the larynx or simultaneously with that of the pharynx" (Xorthrup). 
Croup is more frequent in the country, while diphtheria is more 
prevalent in cities. 

In the opinion of the author, the wide differences between the 
unicists and dualists can be harmonized by recognizing what certainly 
appears to be pathologically and clinically true: that there are two 
varieties of membranous croup, the one diphtheric, the other non- 
diphtheric. "Out of two hundred and eighty-six cases of membranous- 
croup 80 per cent, were diphtheric and 14 per cent, were certainly 
not diphtheric" (Medical Record, September 15, 1894). 

True croup is an idiopathic disease; diphtheria does not arise- 
spontaneously, independently, in isolated instances without inocula- 
tion or infection, directly or indirectly, from a previously existing 
case of the disease, as croup does. The latter is not a contagious, 
inoculable disease; diphtheria is pre-eminently so. Croup does not 
infect the whole system with a profoundly-depressing and exhausting 
poison, causing paralytic sequels, as the diphtheria toxin evolved by 

(458) 



croup. 459 

the Klebs-Loffler bacillus does. The clinical pictures of the two dis- 
eases are similar in their mechanical effects upon the respiration and 
consequent deoxygenation of the blood, but from that point their 
histories are not parallel. Their divergencies are apparent to one who 
has had much experience in their treatment. He must recognize that 
we have a laryngeal diphtheria, on the one hand, and a true croup, 
on the other. Porter agrees with this view, that there is a plastic 
exudation in the larynx which is not diphtheric. 

This is a disease of childhood, and occurs most frequently about 
the second year, and from that to the tenth year. 

Croup is an inflammation of the mucous membrane, mostly con- 
fined to that part of the larynx superior to the vocal bands, but it 
may extend to the trachea. It is attended with the formation of 
an exudate, or inflammatory lymph, that is deposited in the form 
of a fibrinous membrane on the epiglottis, the ventricular bands, and 
to a greater or less extent upon the vocal cords. This false membrane 
does not penetrate the epithelial layer to the submucosa as the diph- 
theric membrane does, but it can be peeled off without tearing the 
mucous membrane or leaving a rough, raw, and bleeding or ulcerating 
surface. If the inflammation extend to the submucosa the laryngeal 
muscles become involved, resulting in spasms or paralysis. 

Etiology. — This disease may arise primarily, without any dis- 
coverable exciting cause, or it may occasionally be secondary to in- 
juries, various irritants, scarlet fever, measles, small-pox, etc. Ex- 
posure to cold and moisture, especially combined with strong winds, 
may give rise to attacks. I have not observed that the previous con- 
dition of health exerted much influence for or against the production 
of croup. Healthy-appearing children seemed to be as easily subject 
to it as those who were badly nourished. The author has had a con- 
siderable opportunity to study these subjects in his practice in con- 
nection with the children's departments of the South-Side and of 
the TTest-Side Free Dispensaries, and, while the children that most 
easily succumbed to diphtheria and other diseases .were the feeble 
and strumous, he has seen the fat and rosy children as often attacked 
by croup as those with impoverished systems. 

The chilling of children by exposing them to draughts of cold 
air; the unpardonable practice of leaving their thighs bare and ex- 
posed to cold, as is the almost universal custom; the carrying or 
wheeling of infants bare-headed in the cold; allowing children im- 
properly clad to sit about in the open air in chilly weather, and to 



460 ceoup. 

rim about the house morning and night in their bare feet in cold 
weather, and similar practices that encourage the shocking of the 
skin by cold and disturbing the balance in the circulation of the blood 
are all prolific causes of croup. 

Symptomatology. — The first thing that may be noticed is the 
hoarseness of the child's voice. Before any fever or subjective symp- 
toms develop the parents may notice the sudden change in quality 
of the voice, but some indisposition may show for several days before 
the attack. Next, a slight cough appears that accentuates the coarse 
timbre of the voice. Its pitch sounds much lower than normal. 
Soon there are signs of fever and complaints of not feeling well. 
If the little one is old enough to describe sensations, headache may 
be spoken of. 

The symptoms often develop with surprising suddenness. The 
child may* appear well during the afternoon, and by 7 o'clock in the 
evening the voice changes to an unnatural hoarse quality, which may 
be overlooked by the untutored or careless until, two or three hours 
later, coughing and difficulty of breathing alarm them to the point 
of summoning medical assistance. With each inspiration now is 
heard the well-known crowing sound of croup. The temperature rises 
to about 103° F. as the night wears wearily on and the obstruction 
to respiration increases with the increasing false membrane. The 
true inflammatory character of the disease is apparent. The pulse 
is accelerated, bounding, and hard; the tongue coated; the skin hot 
and dry; the face red and puffed; and the secretions are checked. 
Unless relief is obtained by expulsion of some of the obstructing mem- 
brane the difficulty of breathing increases until the labor necessitated 
in aerating the lungs is pitiful in the extreme. The sound of the 
prolonged crowing inspiration and the lengthened expiration indicate 
the extreme narrowing of the chink between the vocal bands. As the 
blood becomes poisoned by the lack of oxygen the little one's face, 
flushed at first with a beauteous glow, takes on a bluish tinge that 
darkens as the world grows dark to the little sufferer, until, at last, 
a cyanotic hue announces the approach of death. 

If portions of the false membrane are expelled, more or less 
relief is obtained, and a respite experienced until more membrane is 
formed to take its place, when dyspnoea again ensues. Often the worst 
is over in twenty-four or forty-eight hours, but in other cases the 
duration may be five or six days. 

Diagnosis. — Membranous croup may be mistaken for laryngeal 
diphtheria, acute laryngitis, or laryngismus stridulus. 



TBEATMENT OF CBOTJP. 461 

It may be difficult sometimes to distinguish croup from diph- 
theria. In croup the constitutional disturbance is less profound than 
in diphtheria. Obstruction to breathing is really the principal symp- 
tom of croup. Slight catarrhal symptoms and indisposition may exist 
for several days before the attack of croup, but the diphtheric attack 
is sudden and accompanied with severer symptoms. Croup is neither 
infectious nor contagious; diphtheria is both. In nearly every case 
of diphtheria there is a false membrane in the pharynx, but this is 
not true of croup. The difficult breathing of croup appears suddenly, 
while that of diphtheria is more gradual and lacks the spasm of 
croup. Xo other member of the family or community catches croup; 
diphtheria spreads to others, and has paralysis as a sequel, while croup 
has not. In case of doubt a bacteriological examination should be 
made. 

Acute laryngitis resembles croup in some respects, but it is at- 
tended by more pain in the larynx, less difficulty in respiration, and 
by no formation of false membrane. Croup is a disease of childhood, 
while laryngitis is generally confined to later years. The peculiar 
crowing sound of croup does not occur in laryngitis. The cough of 
the two diseases differs, that of croup having a deeper hoarseness and 
not being so short and hacking as in laryngitis. 

Laryngismus stridulus does not present the symptoms of sickness 
like croup. There is no fever and the labored respiration comes on 
quickly and subsides in a few minutes. The voice remains normal 
between the attacks. 

Prognosis. — Membranous croup is a very fatal disease. Statistics 
show that considerably more than half of the cases die, — 60 to TO 
per cent. Since the introduction of intubation of the larynx by 
O'Dwyer the death-rate has materially improved. In a collective in- 
vestigation by Eanke concerning intubation in Germany he reports 
1445 cases intubated for croup, with 553 recoveries, or 38 per cent. 

O'Dwyer (New Tori- Medical Journal. March 10. 1894) claimed 
that the ''mortality of laryngeal diphtheria without treatment is 90 
per cent., which can be reduced to from 27 per cent, to 4T per cent." 

Attacks of great severity may progress rapidly to a fatal termina- 
tion, the end being induced by a spasm of the glottis occurring in 
a few hours from the seizure. In others the larynx gradually fills 
with the false membrane, depriving the lungs of air until carbonic- 
acid poisoning, coma, and death occur. 

Treatment. — A patient with croup should be kept in a moist at- 



462 TREATMENT OF CEOUP. 

mosphere. I have made it a rule to put the child in a room contain- 
ing a stove, when it is possible. Then, large vessels, like dish-pans 
or boilers, should be placed on the stove and just enough water poured 
in them to cover their bottoms and keep them from burning. Wet 
sheets are hung about the stove, a hot fire is kept up and in this way 
the atmosphere of the room is maintained saturated with steam, and 
at a temperature of 76° or 80° F. If there is paper on the walls, 
it will, of course, be spoiled. 

Unslaked lime is sent for, a bushel or more. A lump as large as 
a man's head is placed in a wooden bucket containing about Jwo 
quarts of hot water. As chemical combination takes place an abund- 
ance of steam is generated which is conducted to the patient's head 
by a tent-shaped arrangement of a sheet. 

In the first, or catarrhal, stage counter-irritation is useful over 
the larynx by means of mustard. An ice-bag (Fig. 83) may modify 
the intensity of the inflammation. Gottstein advises not only these, 
but the use of leeches on the upper part of the sternum. 

Glasgow uses a spray of hydrozone thrown directly into the 
larynx. He believes the mechanical effect of the effervescence pro- 
duced is to detach the false membrane and facilitate its expulsion. For 
the purpose of increasing the secretion of mucus, which has a similar 
effect, menthol crystals may be employed by fusing a few in a tea- 
spoon over a flame until the air is comfortably impregnated with the 
fumes. Inhalations of vinegar are highly recommended by some 
writers. 

Calomel, both internally and externally, has proved a valuable 
remedy. It is believed to be potent in preventing the formation of 
an exudate. It increases the secretions, which action in itself con- 
tributes to the casting off of the false membrane. J. Dundas Grant 
reports favorable results from 1-grain doses every four or six hours. 
With each dose he combines 3 to 5 drops of wine of ipecacuanha and 
3 to 5 grains of bromide of potassium. I have for a long time been 
satisfied that calomel was efficacious, and have employed it in smaller 
doses more frequently administered, 1 / 2 grain every two hours, until 
the bowels were considerably relaxed. I use the sodium bromide in 
preference to the potassium because it contains a larger percentage 
of bromine and is not so vitiating to the blood. 

Fruitnight, in the Archives of Pediatrics for June, 1895, calls 
attention to the value of calomel fumigations in croup, whether looked 
upon as simple or specifically diphtheric. This treatment was origin- 



TREATMENT OF CROUP. 463 

ally suggested some years ago by Corbin, of Brooklyn, and later rec- 
ommended by Dillon Brown. It should be used when there are symp- 
toms of serious laryngeal involvement. "The amount of mercurial 
salt to be vaporized varies from 5 to 20 grains, repeated at intervals 
varying from one-half to two or three hours, according to the severity 
of the symptoms; in the average cases 15 grains hourly. The patient 
is to be kept in the vapor-saturated atmosphere, within a tent, for 
a period varying from ten minutes to one-half hour. In one hun- 
dred cases thus treated no case has been subject to deleterious results. 
In one case only did slight ptyalism occur. Salivation, diarrhoea, 
depression, prostration, and anaemia must be prevented by watchful- 
ness and proper treatment." (Year-book.) 

Emetics play an important role in the urgent stage of croup. 
When the larynx is filling to the degree of threatening suffocation 
a prompt emesis will often loosen the false membrane and effect its 
expulsion. To accomplish this I have most often used turpeth mineral 
(yellow sulphate of mercury) and with the most gratifying results. 
One or two doses will produce vomiting in a few minutes and afford 
marked relief. Ipecac, alum, and sulphate of copper are efficient. 
I have never tried the last of these three. One should guard against 
the tendency of parents or nurses, or wise and more meddlesome 
neighbors, to overdose children with emetics, on account of the ex- 
haustion and the irritability of the stomach which they produce. 
When these measures fail, intubation or tracheotomy must be done. 

Children who are recovering from this disease have very sensitive 
throats and must be protected against cold air and draughts. They 
should be clothed throughout in woolen garments, and kept in-doors 
until a normal condition of the larynx is re-established. Sprays of 
cubebs, camphor-menthol, lavolin, pine-needle oil, oil of tar, etc., will 
assist materially in a complete restoration of the mucous membrane 
to a state of health. 



CHAPTER XXXIX. 
DISEASES OF THE LARYNX, CONTINUED. 

Intubation of the Laeynx. 

To Joseph O'Dwyer, of New York, is due the credit of intro- 
ducing the operation of intubation, which is now so commonly per- 
formed. Bouchut, of Paris, demonstrated in 1858 that the operation 
was practicable, but no practical results followed his discovery until 
O'Dwyer, without knowledge of Bouchufs work, showed actual re- 
coveries due to it. 

The instruments for this procedure are a set of tubes of varying 




Fig. 206. — O'Dwyer's intubation- tubes. 



I 



Fig. 207.— Scale. 



calibre, with a scale for measuring the tube, to assist in selecting the 
proper size; a mouth-gag (Fig. 186); an introducer; an extractor, 
and a protector for the surgeon's finger. 

The tube (Fig. 206) is constructed with a flaring top that rests 
upon the ventricular bands. On one side of the flange is an aperture 
through which a loop of thread sixteen inches long is passed before 
introduction, in order that, if the tube accidentally pass into the 
oesophagus, instead of the larynx, it can be withdrawn. The ob- 
struction of the tube with particles of membrane may also render it 
necessary to draw the tube out by the thread. It is safest to employ 

(464) 



INTUBATION OF THE LARYNX. 



-±05 



a strand of braided silk or linen thread, being certain that it con- 
tains no inequalities to catch in the fenestra. 

The scale (Fig. 20?) is used to determine the size of the tube 
to be employed, according to the age of the patient. 

The introducer (Fig. 208) is screwed into the obturator of the 




Fig. 208. — O'Dwyer's introducer, with tube attached. 

tube, as shown in the illustration, and, when the tube is inserted into 
the larynx, pressure on the button of the introducer separates the 
obturator from the tube, leaving the latter in the larynx while the 
obturator is withdrawn. 

The extractor (Fig. 209) is so constructed that, when the blades 




Fig. 209. — O'Dwyer's extractor. 



at the curved extremity are introduced into the mouth of the tube, 
pressure on the lever will separate the forcep-blades. These are 
roughened so that they obtain a grip that insures the extraction of 
the tube when they are withdrawn. 

In addition to these instruments, one needs a protector against 
being bitten during the operation. J. E. Rhodes (Journal of Hie 



466 INTUBATION OF THE LAKYXX. 

American Medical Association, January 15, 1895) lias "devised a pro- 
tector. It consists of a rubber glove that covers the hand from the 
wrist to a little beyond the metacarpophalangeal joints. On the in- 
dex finger the terminal phalanx only is left uncovered." 

In order to prevent infection through the coughing of a patient 
while the operator occupies a position in front of his mouth, it is 
altogether safest to protect the eyes with glasses and the mouth and 
nose with a respirator or kerchief. 

The operation is a very brief one, not extending over ten seconds. 
The quicker it is accomplished, the less it interferes with respiration, 
and, therefore, with aeration of the blood. One should acquire not 
only extreme dexterity, but gentleness, in order not to do unneces- 
sary damage to the delicate structures encroached upon. With proper 
skill one need inflict no injury or seriously interrupt breathing. In 
selecting the tubes it should be remembered that the smallest is 
intended for children younger than 2 years, the next for those be- 
tween 2 and 4, the third smaller for those between 4 and 6, the 
fourth for those from 6 to 8, and the largest for those over 8 years 
of age. 

After the tube of proper size, according to the age of the child, 
as indicated on the scale, has been chosen, it is attached to the in- 
troducer by screwing the latter into the obturator contained within 
the tube, with the short side of the tube toward the handle, as shown. 
The tube is threaded as already described, and the instrument is laid 
within easy reach of the right hand. Now, the child should be placed 
upon the lap of the nurse or assistant and held as shown in Fig. 187, 
illustrating the operation for removing adenoid vegetations from the 
vault of the pharynx. The position assumed in the direct examina- 
tion of the larynx, or autoscopy, would be a good one for intubation 
if it could be secured (Fig. 201). A strong sheet is wrapped and 
fastened about the child, so as to prevent any freedom of movements 
of its arms and legs, the latter being held between the nurse's knees. 
The nurse passes her left arm around the child's left side and over 
its arm, crosses the little one's wrists, and holds its right hand with 
her left and its left hand with her right, thus making it impossible 
for the child to interfere with the surgeon's work. One assistant 
places the mouth-gag, as shown in the figure referred to, with the 
gag resting between the molar teeth of the left side. He must at- 
tend assiduously to the holding of the gag in place and keeping the 
child's head, thrown a little backward on the nurse's shoulder, im- 



INTUBATION OF THE LARYNX. 467 

movably fixed. If these directions are efficiently followed there can 
he no kicking, sliding down, snatching of the instrument, or disloca- 
tion of the gag. 

The introducer, with tube and obturator attached and previously 
warmed, is then taken, the thread loop is passed over the left little 
finger, and the left index finger, being oiled, is carried into the 
pharynx until its tip rests behind the epiglottis and holds it upward. 
Now the end of the tube is made to follow the course taken by the 
tip of the inserted finger until it rests directly beneath it. The tip 
of the finger readily recognizes the epiglottis and the opening be- 
tween the arytenoid cartilages. The instant the end of the tube rests 
beneath the tip of the finger in the median line, the handle of the 
introducer is brought upward so as to pass the tube from this point 
straight downward into the larynx. Unless this latter direction is 
followed at this particular step of the operation the tube will pass 
back of the larynx into the oesophagus. The tube once in the larynx, 
the thumb pushes the button and the tube is released, the introducer 
withdrawn, and the finger still in the throat presses the tube down 
into proper position. 

The surgeon should not neglect the use of a finger-guard and 
some protector for his eyes, mouth, and nose during the introduc- 
tion of the tube. A bite of the child or the ejection of a diphtheric 
discharge may cost the operator his life or communicate the disease 
to others. 

Before introducing the tube it should be examined to see if the 
instrument work easily, if the tube is readily released, and if it will 
remain safely in position while it is being introduced. The larger 
the tube that can be used, the freer the respiration and the discharge 
of particles of membrane will be through it. 

The thread is best not removed from the tube directly after the 
insertion, for an increase in the embarrassment of the respiration may 
occur, indicating that either false membrane has been pushed along 
below the tube to block up its' lower opening or that the lumen of 
the tube is obstructed by the presence of false membrane or secre- 
tions in it. In either condition the tube must be removed forthwith. 
So the thread loop is secured by attaching another thread to it and 
passing it around the child's neck, and his hands must be kept away 
from it. As soon as it becomes apparent that the operation has 
fulfilled its purpose by affording freedom of breathing, the gag is 
reintroduced, the thread is cut, the finger-tip placed on the end of 



468 INTUBATION OF THE LARYNX. 

the tube to prevent its dislodgment, and the thread loop is with- 
drawn, leaving the tube in position. If the operation has been suc- 
cessful, the patient, relieved of the horror of impending suffocation, 
now drops into a peaceful slumber, which must be encouraged, in 
order that nature may recuperate its waning strength and fortify its 
resisting-powers. 

Pellets of ice may now be allowed the patient to suck for quench- 
ing the thirst and to teach swallowing with the tube in place. Later 
a few drops of cold milk are given for the same purposes. 

Should the first attempt to introduce the tube fail, the child 
must not be exhausted by too immediate an attempt for the second 
trial. A little rest is always best, unless the dyspnoea is exceedingly 
urgent. If the intubation fail or is followed by no relief, trache- 
otomy is the last resort. The physician should always be prepared 
for this emergency by having the tracheotomy instruments at hand. 

A bottle of nitrite of amyl should be provided, for, in case of 
threatened collapse, the inhalation of a few drops of it may resus- 
citate the little patient. 

For the removal of the tube the patient is prepared the same as 
for its introduction. The extractor is carried down, under the guid- 
ance of the tip of the protected left index finger, until it is slipped 
into the opening of the tube, when the lever is pressed upon by the 
thumb, the forcep-blacles expanded to engage the tube, and the in- 
strument is withdrawn with the tube attached. One must not forget 
to keep up the pressure that holds the tube attached to the extractor, 
or the tube might drop back into the throat. Removal of the tube 
may be necessary to clear it of obstructions or to ascertain when the 
patient no longer requires it. Should it be necessary to reintroduce 
it, a second tube had best be at hand already attached to the in- 
troducer, so that, if great dyspnoea occur before one has had time to 
clean and thread the tube removed, the other one can be inserted 
without delay. In case no other tube is at hand Northrup advises to 
"thrust the obturator into the tube and take two turns of thread 
of any kind around the neck of the tube, gathering the two ends in 
the right hand as it grasps the handle. In this way the thread holds 
the tube to the obturator during the insertion, and when it is in the 
larynx unwinds from the shaft and is drawn away." 

After the tube has been in the larynx for a quarter of an hour, 
and there are no indications that it will have to be removed, the 
loop of thread is cut, and, with the finger in the pharynx and rest- 



INTUBATION OF THE LAKYNX. 469 

ing on the end of the tube the same as on its introduction, the 
string is withdrawn. Care must be taken not to disturb the tube in 
doing so. While the thread is in the mouth it excites nausea and 
retching. 

The tube is allowed to remain in the larynx for several days, 
sometimes five or six, but, as soon as it becomes apparent that the 
disease has progressed so favorably as to render its presence there un- 
necessary, it is extracted. Sometimes it is coughed out. 

In the course of three or four hours after intubation the larynx 
becomes accustomed to the presence of the tube; but if fluids are 
administered in a sitting posture they are almost certain to enter 
the larynx and excite violent coughing, which may expel the tube, 
or they may enter the lungs and cause pneumonia. The safest way to 
feed these patients is that proposed by Frank Cary, of Chicago, as 
follows: The patient is placed upon his back, with his feet elevated 
so that the axis of the body rests at an angle of forty-five degrees 
with the plane of the floor. The fluids are given through a tube 
or nursing-bottle in this position; then they do not gain entrance 
into the trachea. Solids do not enter the trachea. Custards, corn- 
starch, thick gruels, etc, are quite readily taken, and many children 
soon learn to eat and drink with the tube in position. 

Intubation is to be preferred to tracheotomy in children under 
5 years, particularly with an abundance of adipose tissue overlying 
the trachea. Parents more readily consent to this procedure than 
to an operation that involves the use of the knife. Intubation pro- 
duces less shock than tracheotomy, and the air is better prepared for 
contact with the mucous membrane below the trachea after intuba- 
tion than when it enters directly through a tracheotomy-tube. Xo 
anaesthesia is required for intubation, but it is generally necessary in 
tracheotomy, although I have operated without an anaesthetic in case 
of emergency. I have seen cases requiring tracheotomy in which the 
time necessary to produce anaesthesia could not be sacrificed, and, 
indeed, the carbonic-acid poisoning produced a sufficient anaesthesia. 

There are instances in which intubation fails because the tube 
cannot be retained in position, or sufficient nourishment cannot be 
taken to support the waning strength, or the tube becomes so clogged 
that it has to be removed repeatedly. In these emergencies trache- 
otomy will have to be brought to our aid. Intubation is not diffi- 
cnlt for the laryngologist, but one needs considerable practice in 
order to be reasonably sure of success. The best means of acquiring 



470 TRACHEOTOMY. 

dexterity is to introduce a tube frequently into the larynx of a 
cadaver. In the absence of conveniences for this, the tube should 
be many times introduced and extracted by means of substituting 
a hand, preferably that of another, for the larynx. The tube should 
be placed completely out of sight in the hand while its aperture 
is sought for with the extractor. But it should not be forgotten that 
the passive hand differs somewhat from an obstreperous, struggling 
child. Intubation requires two assistants, and, if possible, one of 
these should be able to remove the tube or to introduce it if it is 
necessary to remove it or if it is coughed up. So in case of intuba- 
tion it is important that skilled assistance be at hand for these ex- 
igencies. 

Tracheotomy is easier to perform, and can be done in extremi- 
ties without skilled assistants. If the tube become clogged the nurse 
can prevent suffocation by removing it and maintaining the opening 




Fig. 210. — Eos well Park's aluminium tracheal tube. 

free until the surgeon arrives. In these respects tracheotomy pre- 
sents advantages over intubation. In cities where skilled laryngolo- 
gists are within quickly-calling distances intubation possesses superior 
merits. In the country, with all its unavoidable disadvantages, trache- 
otomy is hardly likely to be superseded. 

Tracheotomy. 

The instruments necessary for this operation are a small knife, 
double retractors (Fig. 9-1), haemostatic forceps, tracheal forceps, a 
tenaculum, a grooved director, a flexible catheter, and tracheotomy- 
tubes of various sizes (Figs. 210 and 211). The average size, up to 
3 years, is one-fourth inch (six millimetres). Other convenient arti- 
cles should be at hand, if circumstances permit of their being sup- 
plied: sharp-pointed forceps, an aneurism-needle, thread, absorbent 
gauze, and tapes. 



TKACHEOTO:\IY. 471 

Aii anaesthetic should be given unless the requisite time would 
endanger life, or the diminution of the amount of oxygen reaching 
the lungs would add to a danger already imminent, or unless the sen- 
sibilities are sufficiently obtunded by carbonic-acid poisoning. In 
this operation chloroform is to be given the preference over ether, 
on account of the effect of ether in exciting glottic spasm and in- 
creasing the difficulty of respiration. 

The high operation, in which the trachea is entered above the 
isthmus of the thyroid gland, is generally to be preferred to the low 
one, in which the incision is made below the isthmus, since in the 
high operation there are fewer and smaller blood-vessels to encounter 
(Plate VI). Another advantage gained in the high operation lies in 
the more superficial position of the trachea. 




000 



Fig. 211. — Hard-rubber tracheal tube. 

The position of the patient during the operation is upon the 
back, with the head thrown backward by means of a narrow support 
under the back of the neck, to force upward prominently the ante- 
rior surface of the neck. If the operation is done without anaesthesia, 
the head, hands, and legs must be held by assistants. 

The incision is made in the median line, over the cricoid car- 
tilage, for the high operation, extending an inch or more above and 
below the cartilage. The superficial anterior jugular vein may be 
met with at this point, and requires to be drawn out of the way or 
doubly ligatecl and divided; but, if there is need for great haste, it 
can be secured by haemostatic forceps until after the trachea is opened. 
The superficial fascia is opened, the grooved director inserted, and 



472 TRACHEOTOMY. 

the incision is completed, after which the deep fascia is similarly 
incised. The knife-handle is used to separate the sternohyoid and 
the sternothyroid muscles; the self -retaining retractors (Fig. 94) are 
now inserted to keep the wound open and to check haemorrhage by 
their pressure on its sides. The rings of the trachea can easily be 
felt, and the isthmus of the thyroid gland may protrude sufficiently 
to necessitate its being drawn out of the way. A transverse incision 
is now made, about one-half inch (one centimetre) long, over the 
superior border of the cricoid cartilage, penetrating the superficial 
layer of the deep cervical fascia. The grooved director is then intro- 
duced, passing from above downward between the cricoid cartilage 
and the deep layer of the deep cervical fascia. The two layers of fascia 
with the intervening veins and thyroid isthmus are drawn down- 
ward, exposing the upper rings of the trachea. These are fixed by 
the tenaculum and divided by an incision about one-half inch in 
length, according to the age of the patient. Great care must be 




Fig. 212. — Trachea dilator. 

taken that the knife does not penetrate the posterior wall of the 
trachea and the oesophagus. Equal forethought should insure that 
the false membrane is penetrated, so that the tracheal tube shall not 
be inserted between the membrane and the wall of the trachea, thus 
blocking up its opening. Care must be used to avoid the entrance 
of blood into the trachea and lungs. Coughing generally occurs 
when the trachea is opened, so that the secretions and portions of 
the false membrane are expelled. In case of diphtheria it is evident 
how necessary it is for the physician to be on the alert to dodge the 
bombardment of poisonous discharges. 

The trachea being opened, a dilator (Fig. 212) is employed by 
many surgeons until the haemorrhage ceases and free respiration is 
established. Sponging must be rapid; the opening must be main- 
tained free from discharges; all false membrane within reach of the 
tracheal forceps must be extracted, and, finally, the tracheal tube is 
introduced and secured by tapes passing around the neck and tied 
on one side. As large a tube as the trachea will admit should be 



TRACHEOTOMY. 473 

used. The patient must be closely watched and, if necessary, arti- 
ficial respiration must be performed; clogging of the tube and in- 
terference with it must be prevented. All the tissues about the wound 
should be cleansed with a solution of bichloride of mercury, 1 to 5000, 
and a divided piece of gauze, smeared with carbolized vaselin, should 
be interposed between the collar of the tube and the surface of the 
wound. 

The low operation is performed similarly to the one already de- 
scribed, except that the incision begins at the cricoid cartilage and 
ends about one-half inch above the sternum. The trachea lies deeper 
here; the blood-vessels are larger and more numerous and the thy- 
roid isthmus is in the way. It is a more difficult procedure. 

After tracheotomy the tube is best protected by a layer of bichlo- 
ride gauze kept loosely above and about the tube, without impeding 
the currents of air. As rapidly as it is soiled this protector should 
be removed. The air of the apartment is kept at a uniform tem- 
perature of 76° to 80° F., and impregnated with moisture to prevent 
irritation of the mucous membrane of the deeper air-passages. Dur- 
ing the first day the inner tube must be removed frequently for 
cleaning with a 5-per-cent. solution of carbolic acid, and to make 
certain that there is no obstruction. Sections of the false membrane 
may block up the lower end of the large, or outer, tube and require 
removing with the tracheal forceps. In such an emergency the can- 
nula has to be removed. The nurse should always be instructed as to 
the possibility of such an accident, and that, should it occur, she 
must at once cut the tapes, remove the tube, cleanse and free the 
opening, and maintain its patency until the surgeon can be sum- 
moned. In two or three days the tube should be closed momentarily 
to determine if respiration is normal without it; if so, it can be dis- 
pensed with and the wound closed. 



CHAPTEE XL. 

DISEASES OF THE LARYNX, CONTINUED. 

Cheoxic Laryngitis. 

Synonym. — Chronic catarrh of the larynx. 

Explanatory Note. — Before entering upon a consideration of this 
subject it is pertinent to explain why there is no separate article in 
this book, as is customary, on subacute inflammation of the larynx. 
There are many varying degrees of inflammation of the mucous mem- 
brane. During the same attack of acute inflammation the process 
exhibits different degrees of intensity, but the tendency of our times 
has been too much toward useless and confusing refinements and 
multiplication of pathological conditions into entities, when they 
were really but modifications of the same disease; like shades of the 
same color, there are variations of the same malady. Formerly the 
mild grade of acute inflammation of the middle ear was described 
separately as a subacute inflammation, although it is not a different 
disease;, but the leading books on otology now discard this adventi- 
tious distinction, and laryngologists should lend encouragement to 
a sensible simplification of a terminology which is encumbered with 
unwarranted parasites of nomenclature. So we will not attempt to 
multiply the varying grades of intensity of an acute inflammation 
into separate diseases. 

Pathology. — When acute laryngitis is neglected it naturally 
terminates in a chronic inflammation (Plate VII) which leaves the 
mucous membrane thickened and the small blood-vessels engorged 
and tortuous. There is an increase in connective-tissue formation, the 
encroachment of which on the epithelial layer produces the superficial 
erosions occurring in this disease. The posterior portion of the cav- 
ity only may be involved, or the inflammatory process may extend to 
every part of the larynx, not excepting the muscles. When the latter 
become indurated the mechanism of pitch-production is so inter- 
fered with as to render its changes very difficult. If the mucous mem- 
brane covering the vocal cords is thickened, the result is an alteration 
in the timbre or quality of the voice, which assumes a hoarse sound. 

Etiology. — As chronic rhinitis is the direct result of repeated 

(474) 



PLATE VII. 



PLATE VII. 



Figure 10. — Imperfect view of the larynx resulting from an improper inclina- 
tion of the patient's head, or an incorrect position of the mirror. The head and 
mirror are not carried far enough backward. 

Figure 11. — The conditions are similar to those mentioned in the description 
of Figure 10, but with some improvement, giving a partial view of the laryngeal 
cavity. 

Figure 12. — Omega-shaped larynx of a child. 

Figure 13.- — Hyperemia of the mucous membrane of the larynx, not involving 
the vocal cords or the epiglottis. The vocal cords are in the position of phonation. 

Figure 14. — Congestion of the larynx involving the epiglottis, and the vocal 
cords to a slight degree. 

Figure 15. — Acute laryngitis involving both vocal cords. 

Figure 16. — Acute laryngitis involving the vocal cords and the epiglottis. The 
blood-vessels of the epiglottis are injected; there is an cedematous condition of the 
right half of the larynx. 

Figure 17. — Chronic laryngitis involving the vocal cords, which are ulcerated 
near the posterior commissure. 

Figure 18. — (Edema of the larynx; phlegmonous inflammation. 

Figure 19. — Tubercular infiltration of the arytenoid cartilages, with superficial 
ulceration of the interarytenoid fold and the vocal cords. 

Figure 20. — Tubercular infiltration of the larynx. The epiglottis is pale and 
greatly thickened, together with the arytenoid cartilages, which are pear-shaped. 
The depressions between the cartilages of Wrisberg and Santorini are obliterated. 

Figure 21. — Tuberculosis of the larynx: tumefaction of the arytenoid cartil- 
ages; ulceration of the vocal cords, the left ventricular band, and the interarytenoid 
membrane. 



PLATE VI 




10 




t^ : 



m 




12 




15 



18 



19 





20 



21 




BUFK B McFETTWGE CO. 1/77/. PHIL' 



CHBOXIC LARYNGITIS. 475 

or neglected attacks of acute nasal catarrh, so chronic laryngitis may 
be a sequel of recurring or neglected attacks of acute catarrh of the 
larynx. But this disease is not always a heritage of an acute attack. 
It often arises spontaneously. Many patients who are afflicted with 
chronic hypertrophic rhinitis present a chronic laryngitis as a com- 
plication or result of the nasal hypertrophy. This is easily under- 
stood when we take into consideration the continuity of mucous mem- 
brane of the larynx, pharynx, and nasal cavities. In addition to this 
direct cause is another which illustrates the importance of prompt 
and efficient treatment of nasal anomalies. The discharges from the 
nose and naso-pharynx constantly find their way either directly into 
the larynx by dripping into the cavity, or they gravitate down to the 
immediate vicinity of the portal of the larynx, where they cause direct 
irritation by their presence, and indirect irritation by exciting efforts 
to dislodge them with a hacking cough. Bosworth lays stress upon 
this source of chronic laryngitis. 

Another causative relation of hypertrophic rhinitis to this dis- 
ease lies in the forced mouth-breathing in consequence of nasal steno- 
sis. The air then reaches the larynx without the processes of puri- 
fying, warming, and moistening having been applied to it as they are 
by the nasal passages in a normal condition. 

Excessive use of the voice, especially when it is taxed beyond 
its natural or acquired compass, sets up an hyperemia and congestion 
that finally terminate in a chronic inflammation. Ambitious, but 
ill-trained singers, the periodical orators of political campaigns, huck- 
sters, intensely-emotional revivalists, etc., are frequent sufferers. In- 
activity of the liver, and dyspepsia, alcoholic excesses, and atmos- 
pheric irritants are prolific producers of this disease. According to 
the observations of Ziemssen and Mulhall, boys are rendered sus- 
ceptible to attacks of catarrhal laryngitis by the changes incident to 
the age of puberty. 

Symptomatology. — The most marked symptoms are developed 
when attempts are made to use the voice. While it is at rest there 
may be very little to call the patient's attention to the fact that he 
has a larynx. In other instances there is a sensation of dryness or a 
slight irritation that excites a hemming or a little cough. But when 
the patient begins to call the vocal organs into activity the trouble 
begins. A tickling sensation is experienced that produces an irre- 
sistible desire to cough. Burning and prickling pains are felt in the 
larynx, which one endeavors to relieve by clearing the throat. In 



-±76 CHRONIC LARYNGITIS. 

the midst of a sentence a cutting pain shoots- through the organ, 
that may be described as a feeling as though the vocal cords were 
splitting or tearing. The sentence, or even the word, is cut short, 
and for an instant the speaker is unable to proceed until he clears 
the throat or takes a drink; hence arises the habit of many speakers 
of providing themselves with a glass or a pitcher of water before be- 
ginning a discourse. 

The voice shows the most marked effect of this disease, but 
there are great variations in different patients, and peculiarities dis- 
tinguishing certain cases. When a speaker, for example, begins an 
address, his voice may be husky and cracked in quality, while, after 
proceeding for a short time, the normal timbre may be restored. 
Singers experience the same peculiarity. This is probably due to 
the increased secretion stimulated by a quickened circulation, as well as 
to improved innervation resulting from the intensity of will-impulse. 
Another characteristic is the natural quality observed in the cus- 
tomary tones and the breaking of this quality on straining the voice, 
and even a condition of complete aphonia, or loss of voice. 

The secretions are not copious in uncomplicated chronic laryn- 
gitis. They are generally tenacious and of a gray color, but if ulcera- 
tions are present they assume a yellow hue. As in the acute inflam- 
mation, there is rarely any blood in the expectorations, unless an 
unusually violent effort at coughing has ruptured the vessels. 

Inspection with the laryngeal mirror shows an hypergeniic con- 
dition of the mucous membrane (Plate VII). As the figures illustrate, 
the small blood-vessels of the epiglottis are engorged and conspicu- 
ous. The vocal cords are sometimes red, one or both of them; at 
other times they do not participate in the inflammatory process. One 
cord may be affected, while the other remains of normal appearance, 
or parts only of the cords may show an injected condition of their 
blood-vessels. These parts are the lateral attached borders of the 
vocal bands. The condition of the membrane varies, according to 
the amount of secretions present, from absolute dryness to a general 
covering of the whole interior with secretions. Like similar condi- 
tions of the mucous membrane in other localities, a gradual thicken- 
ing of the mucosa and submucous tissues results from inflammation 
of long duration, and the vocal cords may be affected by this hyper- 
plasia to the extent of granulation formation, or trachoma. The 
presence of these excrescences materially embarrasses the vibration of 
the cords and changes the character of the notes produced. 



CHROXIC LARYXGITIS. -IT? 

The chronic thickening of the mucosa and the subjacent tissues 
diminishes the mobility of the larynx, just as we have seen that the 
increased thickness of the drum-head and of the tissues entering into 
the construction of the joints of the ossicles and the attachment of 
the stirrup to the oval window diminishes or destroys their mobility. 
For example of impeded movements due to hypertrophy: when the 
interarytenoid fold becomes thickened the arytenoid cartilages cannot 
approximate each other normally, which is equivalent to saying that 
the vocal bands cannot do the same thing. Great swelling of the 
ventricular hands obliterates the ventricles and deranges the actions 
of the vocal cords. One cord becomes paretic (Plate YIII) and the 
opposite cord must do vicarious service, which it does by taking the 
place, almost literally, of its fellow, by moving across the median line 
to approximate its useless mate. The gap is then closed up, to a de- 
gree, and voice-production is made possible. 

Ulcerations of a shallow kind are occasionally to be seen, gen- 
erally in the interval between the arytenoid cartilages. 

Diagnosis. — Chronic laryngitis is likely to be confounded with 
laryngeal oedema (Plate VII), paralysis, and cancer, or syphilitic and 
tubercular laryngitis. In oedema the swelling of the mucosa is out 
of all proportion to the thickening of chronic inflammation, and, 
although there may be redness, there is generally a pale, puffy, and 
water-soaked appearance, and the disease is of short duration. In 
paralysis neither swelling nor congestion is present. In the catarrhal 
condition hoarseness is generally more apparent in the morning hours, 
while the change in character of the voice in paralysis is constant, 
but less noticeable immediately after a night's rest. Paresis in the 
catarrhal condition more often affects one vocal band than both, ac- 
cording to Ziemssen; and the absence of mobility is much greater 
in paralysis. In catarrh the use of the voice often has the effect of 
clearing it of its cracked quality, while in paralysis fatigue and vocal 
exercise impair its quality. 

Tubercular laryngitis presents a very different history from that 
of the simple catarrhal disease. The general condition of the patient 
ami the presence of a tubercular condition of the lungs assist ma- 
terially in making a differential diagnosis. The impaired nutrition 
and strength, the temperature and pulse, the night-sweats, and painful 
and difficult swallowing are characteristic of tuberculosis, but not of 
chronic laryngitis. The intralaryngeal pictures show certain dif- 
ferences in the two diseases. While redness is a symptom of catarrhal 



iT8 TREATMENT OF CHRONIC LAEYNGITIS. 

inflammation, the membrane in tuberculosis of the larynx may pre- 
sent a bloodless appearance, especially in the initiatory stage of the 
disease. Erosions, rare in simple catarrh, are characteristic of the 
tubercular affection. In laryngitis of the simple type, even when 
the erosions are found, they are superficial points of exfoliation of 
the epithelium; but in tuberculosis they may extend deeply into the 
membrane and be distributed over a wide area (Plate VII), affecting 
the epiglottis, the posterior commissure, the ventricular bands, and 
the vocal cords. The polypoid conformation of the arytenoid car- 
tilages produced by the great thickening in advanced cases is well 
illustrated in the plate to which reference is made. This swelling 
extends to the aryepiglottic folds and appears dense instead of cedema- 
tous, although the paleness of the membrane may be suggestive of a 
case of oedema. 

Syphilis of the larynx (Plate YIII) may closely simulate a simple 
catarrh, but a syphilitic history or the presence of ulcers or their 
scars, and deformities due to the contraction of old cicatrices are 
valuable aids to diagnosis. The effects of the administration of spe- 
cific remedies in experimental diagnosis are determinative in syphilis. 

In both tuberculosis and syphilis of the larynx characteristic 
lesions in the pharynx may help greatly in arriving at a correct con- 
clusion. 

Chronic laryngitis may be with difficulty distinguished from a 
malignant disease, at first, but the histories of the two conditions 
vary. In the early stage of malignant disease the red, tumefied ap- 
pearance is limited to a certain area instead of being diffused over a 
large surface. As the neoplasm increases in size it changes the con- 
tour of the parts as simple catarrh does not, and difficult and painful 
swallowing, together with loss of voice, are marked symptoms of 
malignant disease. As deep ulceration in the latter condition takes 
place the pain is more pronounced and continuous than is met with 
in simple chronic laryngitis. 

Prognosis. — If the disease has not existed too long, and proper 
treatment and hygienic conditions can be had, the outlook is favor- 
able. But if thickening of the tissues is great and extends to the 
laryngeal muscles, the difficulties to overcome are considerable. This 
trouble is usually protracted and extends over many years, in some 
cases, and, after treatment has accomplished all it will, the voice may 
still retain a coarse, unpleasant quality. 

Treatment. — The topical application of remedies is easily accom- 



TREATMENT OF CHRONIC LARYNGITIS. 



479 



plislied with the improved apparatus of our day. Compressed air and 
sprays can be made to apply medicaments to the interior of the larynx 
with ease and efficiency. Useful devices are shown in Chapter XVIII 
for both office and home treatment. Improved appliances for com- 
pressing air, both by hand and hydraulic power, are described in Chap- 
ter IV. 

Various medicated sprays — as recommended by Lennox Browne, 
E. L. Shurly, Charles E. de M. Sajous, and others — will cleanse and 
disinfect the larynx, as well as produce astringent, sedative, stimu- 
lant, or tonic effects. It is claimed by Eoe and Cohen that sprays 
thrown into the throat are largely condensed in the pharynx, but 
it can be easily demonstrated upon one's own larynx that the remedy 
can be made to medicate that organ also. If the spray is thrown 
through a long tube with a properly-curved extremity (Figs. 127 and 
128) for directing the current downward and a little forward from a 




Fio-. 213. — Laryngeal cotton foiveus. 



position similar to that occupied by the laryngeal mirror in situ, the 
spray enters directly into the larynx. When the nebulizer is used 
with the lips closed over the mouth-tube and the patient inhaling 
through the instrument, the medicinal vapor not only reaches the 
laryngeal cavity, but the bronchi and lungs also. In former years 
I used the complete steam-atomizer of Codman & Shurtleff, but. as 
I could not discover compensating advantages of the steam method 
over the improved apparatus referred to, and as the latter requires 
far less time and trouble in giving treatments, I have for a consider- 
able time preferred the instruments described. 

Eor the application of pigments to the laryngeal membrane spe- 
cial camel's hair brushes, sponges, and cotton are used. I prefer the 
cotton, either twisted firmly on a holder or used with Cohen's laryn- 
geal cotton-forceps (Fig. 213). The bristles of the brush sometimes 
become detached and stick in the larynx, like the voice of JEneas. 
This is not amusing to the patient. Applicators for caustics are spe- 



480 ATROPHIC LARYNGITIS. 

cially constructed, but, with a minute cotton-tip twisted very firmly 
on a carrier, escharotics can be conveniently applied. 

Counter-irritants, like mustard and tincture of iodine, are some- 
times serviceable. They should be applied to the skin directly over 
the larynx and at its sides. It is exceedingly important that the cause 
of the trouble be removed, and this will generally be found to lie in 
inordinate and improper exertion of the voice. In such cases absolute 
rest must be enjoined. When the cough is very troublesome the com- 
pound spirit of chloroform or Hoffmann's anodyne will relieve the 
irritation. The inhalation of camphor-menthol from the pocket-in- 
haler (Fig. 141) allays the tickling sensation. 

When the thickening of the membrane is considerable, sprays 
of eucalyptol, 4 per cent.; camphor-menthol, 3 per cent.; or oil of 
cubebs, 4 per cent., in lavolin should be used once or twice a day. 
Alum, in a 2-per-cent. solution; zinc sulphate, 1 per cent.; or silver 
nitrate may be used according to the indications in each case. When 
much irritability exists, with a hacking cough and copious secretions 
and expectoration, inhalations of a 10-per-cent. solution of camphor- 
menthol in lavolin are effective. These should be taken through the 
nebulizer, and not in the form of a coarse spray. 

If erosions are discovered, hyclrozone, diluted one-half with warm 
water, at first, should be sprayed upon the ulcers; then aristol should 
be sprinkled over them. Iodoform is preferred by some, tannin and 
alum by others. Chromic acid, 5 or 10 grains to the ounce, and silver 
nitrate have able advocates. 

Atrophic Laryngitis. 

For the pathology of atrophic conditions of the mucous mem- 
brane, see "Atrophic Khinitis." 

This requires stimulating applications. The lavolin-sprays con- 
taining the remedies already given are useful, — viz., eucalyptol, oil 
of cubebs, benzoinated lavolin, menthol, terebene, salol, oil of tar, 
etc. Shurly recommends iodine internally in the form of hydriodic 
acid, in drachm doses, three times a day, or iodide of potassium or 
ammonium. Much relief is afforded by my ammonium-chloride 
tablets, the formula of which will be found on page 339. Two or 
three can be used in the course of an hour, allowing them to dissolve 
slowly in the mouth, so that the medicated saliva will trickle down 
and remain in contact wth the mucous membrane about the entrance 
to the larynx as long as possible. 



suppukative laryngitis. 481 

Suppueative Laryngitis. 

Synonyms. — Phlegmonous laryngitis; purulent laryngitis; dif- 
fuse abscess of the larynx. 

Pathology. — This is an inflammation of the submucous tissues 
of the larynx (Plate VII), with infiltration of the areolar tissue and 
suppuration, ending in the formation of abscesses. The area most 
frequently involved is the superior part of the larynx, contiguous to 
the epiglottis. 

Etiology. — Suppurative inflammation of the larynx may be 
idiopathic, or it may arise secondarily by extension from the pharynx. 
It may originate in a perichondritis which is secondary to syphilitic 
infection or other wasting disease. 

Symptomatology. — Difficult respiration and impairment or sup- 
pression of the voice are the most prominent symptoms. There is 
a choking or stifling sensation, as though a foreign substance -had 
gained entrance into the larynx, accompanied by increasing pains. 
Some difficulty in deglutition appears; all the symptoms become ex- 
aggerated; the breathing is strident, the voice feeble and cracked, 
the face puffed and purple, and suffocation seems imminent. Fre- 
quent attempts are made to free the throat by hemming rather than 
by coughing. Laryngoscopy reveals the inflamed, tumefied mucous 
membrane obstructing the air-current. Circumscribed swelling may 
be seen in the region of the aryteno-epiglottic folds, and other parts 
of the larynx may become (Edematous. 

Diagnosis. — Inspection discloses the differences between this dis- 
ease and the presence of foreign bodies, diphtheria, croup, tumors, 
pharyngeal abscess, and spasmodic croup. The dyspnoea of this dis- 
ease appears more gradually than that occasioned by the presence 
of foreign bodies or laryngismus stridulus, in which the obstruction 
to breathing occurs suddenly. The history of a tumor does not pre- 
sent the characteristics of an inflammation. 

Prognosis. — Suppurative laryngitis is a rapidly-fatal disease. It 
kills about three out of four of its victims. Death is caused by 
strangulation or inanition. 

Treatment. — If the patient is seen at the onset of the attack, 
cold, in the form of ice-bags (Fig. 83), should be constantly applied 
over the larynx. Pellets of ice may be sucked so as to produce the 
effect of cold internally as well as externally. Leeches may be applied 
over the upper portion of the sternum, but in this disease there is 
one objection to them that may not have weight in other diseases of 



482 (EDEMA OF THE LARYNX. 

the larynx, — i.e., the patient soon becomes exhausted from the lack 
of nourishment, owing to the impossibility of swallowing sufficient 
food, and bleeding only adds to his weakness. The air should be kept 
moist, the same as in croup. (Edematous tissue and abscesses must 
be evacuated by scarification. Supportive and stimulant treatment 
must be combined with nutritious enemata to meet the inevitable fail- 
ure of strength. Suffocation must be prevented by tracheotomy or 
intubation. 

Abscess oe the Larynx. 

The physical conditions in this disease coincide so closely with 
those just described under the heading of "Suppurative Laryngitis/' 
in which abscesses occur, that a separate description would be tanta- 
mount to tautology. The treatment is the same as for abscesses oc- 
curring in suppurative laryngitis. 

Trachoma oe the Vocal Cords. 

As a result of chronic laryngitis of long duration, a roughened 
condition of the vocal bands is found, to which the name "chorclitis 
tuberosa," or granulations, is sometimes applied. There is a prolifera- 
tion of connective tissue, productive of inequalities that are apparent 
in the laryngoscopic image. This condition obtains most frequently 
in public speakers and singers and is sometimes quite intractable to 
treatment. F. I. Knight claims that the granulations may disappear 
without treatment. 

Treatment. — The remedies recommended for chronic laryngitis 
are applicable here. Charles E. de M. Sajous advises applying chromic 
acid to the cocainized hypertrophies. This is best accomplished by 
fusing the acid on a protected applicator, bent to the proper curve. 
Only a few of the prominent points should be touched at each treat- 
ment. Silver nitrate is preferred by Eice and Cohen, and the curette 
by Heryng. The biting curette (Fig. 214) or the electrocautery may 
be adapted to certain cases. The writer prefers the electrocautery, 
but has employed the chromic-acid and silver-nitrate beads with satis- 
factory results. 

(Edema of the Larynx. 

Synonyms. — (Edematous laryngitis; purulent laryngitis; oedema 
glottidis. 



(EDEMA OF THE LAEYXX. 483 

Pathology. — The loose attachment of the mucous membrane to 
the walls of the larynx favors infiltration and separation of the mu- 
cosa from the cartilages (Plate VII). The changes that take place in 
acute (Edematous inflammation occur so rapidly as to preclude their 
study, the disease proving rapidly fatal in many cases. In this form 
the infiltration consists of serum, but in the more protracted attacks 
it consists of a mixture of serum and pus, with effusion of blood in 
occasional instances. The epiglottis is sometimes involved to the 
extent of becoming greatly enlarged. The loose areolar tissue of the 
aryepiglottic folds is probably more copiously engorged with the fluid 
exudate than any other portion of the larynx, and the ventricular 
bands suffer nearly as much. The true vocal bands may escape alto- 
gether or participate to the degree of slight swelling. The laryngeal 
muscles may present a water-soaked appearance if a post-mortem ex- 
amination is made, after death due to this disease. Associated with 
oedema of the larynx may be a similar infiltration of the pharynx and 
even of the neck. 

Etiology. — Most cases of laryngeal cedema occur between the 
ages of 20 and 35 years, and are nearly three times as frequent in men 
as in women. It may be idiopathic or symptomatic. Xearly three 
times as many cases are secondary as are primary in character, — that 
is, most cases are consecutive to some other affection, such as Bright's 
disease, that gives rise to a dropsical condition of lax tissues. "When 
oedema of the pharynx invades the adjacent laryngeal tissues, the 
latter is termed "contiguous oedema"; and when laryngeal oedema is 
secondary to some other disease of the larynx it is designated as con- 
secutive. Any cause that operates to produce inflammation of the lar- 
yngeal mucosa or submucosa may be a cause of cedema. Exposure to 
cold or impure air containing irritating particles or gases, injuries, 
scalds, corroding chemicals, and certain diseases cause or predispose 
to this disease. Such affections as Bright's disease, syphilis, tuber- 
culosis, and typhoid and the eruptive fevers. 

Symptomatology. — The prominent and most distressing symp- 
tom is the difficulty of respiration. There is a sensation as if a foreign 
body had gained entrance into the throat, and difficulty of swallowing 
adds to the suffering. As the swelling and consequent stenosis of the 
larynx progresses, the labor of breathing becomes more arduous, until 
the patient is threatened with impending suffocation. As the lumen 
of the larynx is encroached upon, and the pressure of the tumefied 
tissues increases, the voice becomes feeble and finally disappears. 



4:84: (EDEMA OF THE LAKYNX. 

Frequent efforts are made to clear the throat of the obstruction, 
but they are not of the character of a cough. There is but little 
expectoration, and this consists of mucus. The suffering occasioned 
by this disease is intense, not only of the patient, but of his helpless 
friends. He cannot lie down, but sits with his body and head thrown 
forward, unable to speak, but exerting every muscle to draw in enough 
air to support life. He calls to the by-standers for help, has them 
support his arms and shoulders, one attendant on either side, while 
he seeks the open window for air. The noise of inspiration is harsh 
and indicative of the extreme narrowing of the glottis. Moments 
of relaxation and relief may occur, only to be followed by the par- 
oxysm that threatens immediate suffocation. As the sufferer gasps 
for air, with open mouth and horror-stricken eyes, his face puffed and 
purple, his whole frame convulsed with an agonizing struggle for life, 
the surgeon or death soon comes to his relief and closes the scene. 

Inspection, when it is possible, reveals the epiglottis red and 
swollen to enormous proportions, and it may cut off a view of the 
laryngeal cavity. The enlargement becomes so excessive as to amount 
to a deformity. The aryepiglottic folds are seen to be tumefied even 
to the point of medial contact with each other over the laryngeal 
opening during inspiration. 

When inspection is impossible, a quick, but gentle, palpation 
with the finger, not interrupting respiration to a dangerous degree, 
may enlighten the examiner as to the condition present. The roll- 
like character of the epiglottis and the spongy feeling of the aryepi- 
glottic folds are characteristic. 

Diagnosis. — (Edema of the larynx may be mistaken for the pres- 
ence of foreign bodies, polypus, retropharyngeal abscess (Plate V), 
acute laryngitis (Plate VII), or pulmonary emphysema. The symp- 
toms and the conditions presented on examination are sufficient to 
mark the differences. Diphtheria of the larynx can be detected by 
the discharge of shreds of the false membrane, and the latter is gen- 
erally found in the pharynx also. 

Prognosis. — About one-half of all cases of this disease terminate 
fatally. Acute laryngeal oedema has an average duration of about a 
week. Cases arising in the course of pharyngeal oedema generally 
pursue a favorable course, but those resulting from aneurism of the 
aorta or of other important vessels of the neck prove fatal. The 
same is true of oedema arising from an extension of the disease from 
the external areolar tissue. Tubercular oedema is unfavorable, but 



TREATMENT OF (EDEMA OF THE LARYNX. 485 

the syphilitic type is amenable to treatment. The prognosis should 
always be guarded. 

Treatment. — Scarification is the classic remedy, but there are 
other means of relief that have come into use in later years. Pilocar- 
pine depletes the blood-vessels of their serum and is indicated here 
to drain the water-soaked tissues. It can be given in closes of 1 / 8 or 
Vie g' r ain until free salivation and diaphoresis are produced. Enough 
to cause heart-depression should not be administered. 

In violent acute cases the blanching, shrinking, and anaesthetic 
effects of cocaine would appear to be indicated. I have never tried it 
in this condition, nor have I seen it mentioned in this connection, 
but for prompt action and immediate relief from impending suffoca- 
tion its physiological action suggests its use. Unless a speedy change 
for the better takes place, scarification, intubation, or tracheotomy 
should be done. 

When oedema has become chronic, its treatment is much like 
that of chronic laryngitis, with the addition of scarification. Dilata- 
tion by Schrotter's method with hard-rubber tubes has proved useful, 
and the intubation-tubes promise good results. In severe cases 
tracheotomy may become imperative. 



CHAPTER XLI. 
DISEASES OF THE LARYNX, CONTINUED. 

Leukoses. 

spasmodic ckoup. 

Synonyms. — Spasm of the larynx; spasm of the glottis; laryn- 
gismus stridulus. 

Pathology. — According to Marshall Hall, this is a reflex nervous 
disease the exciting cause of which may be located in remote organs, 
— for example, in the teeth, the intestinal tract, or at a point of 
pressure on the recurrent laryngeal nerve. It is believed by some 
authorities to be of purely cerebral origin. 

Etiology. — This is, for the most part, a disease of childhood, 
although it occasionally occurs in adult life. It may be brought on 
by the accidental entrance of liquid or food or any foreign body 
into the larynx. Dentition is a common cause, and mental emotion 
may give rise to attacks. 

Symptomatology. — The closure of the glottis may be complete 
or incomplete. In the former case there is entire arrest of respiration 
temporarily. The child is taken with a sudden convulsion; the eyes 
are rolled; the hands and feet are cramped, and even opisthotonos 
may supervene. All at once a spasmodic inspiratory movement occurs, 
announcing the cessation of the spasm. When the glottis is incom- 
pletely closed, the air passes through it with a harsh, croupy sound, 
which resembles closely the crowing of croup or the whoop of whoop- 
ing-cough. During these distressing attacks the face becomes flushed, 
congested, or livid, according to the severity of the attack, and the 
veins of the neck are distended. In extreme cases the spasm does not 
relax and the child dies in convulsions. 

These attacks may follow each other rapidly, or one only may 
occur at long intervals, and the child appears in excellent health be- 
tween the attacks. They occur usually at night, waking the child out 
of a sound sleep. They are not accompanied by fever or cough, but 
there is copious perspiration. Children under 2 years of age are most 
frequently subject to this disease, and boys are attacked more often 

(486) 



NEUROSES OF THE LARYNX. 487 

than girls. Those whose systems are impoverished are the most likely 
to suffer. In this respect spasmodic croup differs from true croup. 

Diagnosis. — Spasmodic croup does not closely resemble any other 
disease except true croup, from which it can be differentiated by the 
absence of fever and false membrane and by the presence of good 
health as soon as the transitory paroxysm yields and normal respira- 
tion succeeds. 

Prognosis. — When the attacks do not show a high degree of in- 
tensity of the spasmodic contraction, and when they do not last long 
or do not occur at short intervals, the prognosis is usually favorable. 
But when the closure of the glottis is complete the child may die of 
strangulation before help can be summoned. The more frequently 
the paroxysms occur, the more danger there is to life. If the spasms 
are owed to cerebral disease the prognosis is grave. 

Treatment. — For immediate relief a few drops of amyl-nitrite, 
ethyl-bromide, chloroform, or ether may be inhaled, if any air is 
inspired. If not, dashing cold water in the face, slapping the back 
of the shoulders, applying ice to the back of the neck, tickling the 
throat, or introducing the finger to cause vomiting may succeed in 
aborting the attack. "While the finger is in the throat it should be 
used to learn whether the epiglottis is impacted in the aperture of 
the larynx, and, if it is, the tip of the finger should be hooked under 
the epiglottis and made to raise it into position. Drawing the tongue 
out of the mouth also raises the epiglottis. A hot mustard bath may 
relax the spasm. Hypodermic injections of apomorphine, in very 
minute doses, or a dose of turpeth mineral, 1 or 2 grains, may excite 
vomiting and end the paroxysm. Powdered alum in teaspoonful 
doses is a harmless and efficient emetic. 

The cause of the attacks must be ascertained and prophylactic 
measures adopted. Laryngitis, indigestion, troublesome teeth, or 
irritation of the genital organs, especially of the prepuce, may bear 
a causative relation to this disease. As a rule, general tonics, nervous 
sedatives, and an especially nutritious diet are indicated. 

ANOMALIES OF SENSATION. 

Hyperesthesia, neuralgia, and paresthesia of the larynx are 
most commonly met with in singers and public speakers who strain 
their vocal organs. 

Pathology. — Congestion of the laryngeal mucous membrane is 
often present, but inspection may not reveal any apparent structural 



488 TKEATMENT OF ANOMALIES OF SENSATION. 

change; this is true when the affection is purely of a neurotic char- 
acter. 

Etiology. — Excessive use of the voice after faulty methods, over- 
indulgence in alcoholic beverages, excessive smoking, varicose veins 
and hypertrophied glands at the base of the tongue, and inflamma- 
tory affections of the larynx occasion hyperesthesia. The causes of 
paresthesia are quite numerous and sometimes obscure. Anything 
that produces a depressed condition of the nervous system may be 
said to predispose to this nervous anomaly. Foreign bodies in the 
larynx and inflammatory conditions of the mucous membrane cause 
it. To these causes, and to the uric-acid diathesis, neuralgia is due. 

Symptomatology. — The laryngeal mucous membrane is often ex- 
quisitely sensitive in hyperesthesia, so that dusty or cold air, the 
fumes of a match, smoke, etc., provoke fits of coughing. There is 
usually a sensation of dryness, or scratching, or tickling in the larynx 
that excites hemming or slight coughing to give relief. Neuralgia 
here, as elsewhere, is not constant. Fugitive pains and sensations of 
soreness of a transitory nature are present. In paresthesia there are 
unusual sensations, generally of a foreign body in the larynx. Pa- 
tients sometimes can scarcely be convinced that the impression is 
not produced by a foreign substance. This is called globus hystericus. 

Diagnosis. — There is not much difficulty in deciding upon the 
nervous nature of these affections, since examination generally fails 
to discover any physical signs. The symptoms are quite character- 
istic. 

Prognosis. — These troubles are rather annoying than serious. 
They are persistent, but amenable to treatment. 

Treatment. — If any irritation is found, the throat-tablets — con- 
taining ammonium chloride, 1 grain; camphorated tincture of opium, 
compound syrup of squills, and syrup of Tolu, each 5 minims; and 
extract of licorice, 3 grains — may allay the irritation and cough. In- 
halations of oil of cubebs, carbolic acid, salol, and eucalyptus in lavo- 
lin, as described under the heading of "Sprays and Inhalents," are 
beneficial. When hypertrophied glands and varicose veins are found 
in the pharynx, and especially about the base of the tongue, they 
are to be eradicated by means of the cautery. The bromides and 
other nervous sedatives and nervous stimulants, like valerianate of 
ammonia, are demanded in certain cases. General tonic treatment is 
often necessary, combined with a fattening regimen. 

W. Peyre Porcher emphasizes the fact that the lithic-acicl di- 



NERVOUS APHOXIA. 489 

athesis may stand in a causative relation to these neuroses, and that 
such cases must receive antirheumatic treatment, including colchi- 
cum, salol, guaiac, the salicylates, etc. 



NERVOUS APHOXIA. 

Synonyms. — Hysterical aphonia; hysterical paralysis of the vocal 
cords; functional aphonia. 

Pathology. — This is a functional bilateral paresis of the lateral 
cricoarytenoid muscles, interfering with the normal relations of the 
vocal cords during attempted phonation. They cannot be properly 
-approximated. It is not due to any organic lesion, but to a temporary 
loss of the power of muscular co-ordination or of innervation. 

Etiology. — This affection is a symptom of hysteria and debili- 
tating diseases. It occurs most frequently in unmarried women, and 
is especially marked between puberty and the establishment of the 
menopause. 

Symptomatology. — A peculiarity of this disease is that the pa- 
tient may not be able to utter the common conversational tone, but 
may cough or laugh audibly, which does not occur in complete pa- 
ralysis. The onset is sudden, like that of spasmodic croup, and the 
patient cannot attribute it to any cause; or it may follow upon an 
intense mental impression. Even whispering is sometimes out of the 
question. The attacks are irregular, appearing one day and disap- 
pearing the next, without any premonitory signs or symptoms. The 
impression of cold often develops the symptoms, and this fact may 
account for patients, exposed to draughts of air at night, losing their 
voices between the hours of retiring and arising. 

Inspection during phonation shows the effect of the loss of power 
of the adductors. The vocal cords cannot be brought into close re- 
lationship. Efforts to approximate them may cause a spasmodic ap- 
proaching of the cords, followed immediately by their wide separation. 
Unless a catarrhal condition exists, the larynx is pale and presents no 
inflammatory appearances. 

Diagnosis. — The history, symptoms, and appearances described 
render the diagnosis easy. 

Prognosis. — This is favorable, although there is a liability of 
the attacks to return. This is the kind of trouble in which the vari- 
ous sorts of "mind-cures" are effective. The mental impression made 
by simply introducing any indifferent instrument, such as a laryngeal 



490 REFLEX AFFECTIONS OF THE VOICE. 

mirror, into the throat may restore the voice. In other cases actual 
treatment must he pursued for a considerable time to effect a cure. 

Treatment. — Strychnine, beginning with 1 / 30 grain and increased 
gradually until its physiological effects are produced, and electricity 
are efficient remedies. Sir Morell Mackenzie devised a laryngeal elec- 
trode for this purpose, by means of which one electrode is applied 
within and the other without the larynx. The galvano-faradic cur- 
rent is preferable. If the muscles have not become atrophied this 
treatment is speedily beneficial. 

The elixir of the valerianate of ammonia, combined with quinine,, 
if a tonic effect is desired in addition to that of a diffusive nervous- 
stimulant, meets the indication admirably. Zinc valerianate in 1- 
grain closes every four hours is recommended by Sajous, as well as 
coca-wine. 



EEFLEX AFFECTIONS OF THE VOICE. 

The condition of the vocal cords is affected by certain states of 
the generative organs. Singularly enough, the same causes seem to 
produce opposite effects in different subjects. The author has ob- 
served that in some soprano singers the occurrence of the menses is 
accompanied by a huskiness, or roughness of timbre, of the voice;, 
but in others the same periods are characterized by a clearer, fuller, 
and more flute-like quality of tone. However, the latter effect is 
probably exceptional. Uterine and ovarian diseases have a deleterious- 
effect on the voice, especially noticeable in the singing voice, and any 
treatment to restore the voice-deterioration must include gynaeco- 
logical measures. C. H. Leonard has reported cases in which voices- 
impaired by uterine disease have been restored, and in one case two 
full notes were said to have been added to the upper register of a high 
mezzosoprano as a result of uterine treatment. In the latter case 
there were anteflexion, narrowing of the uterine canal, and endome- 
tritis. 

These facts are not surprising when we consider the close sympa- 
thetic relations existing between the uterus and the central nervous 
system. Bischoff has shown that division of the spinal accessory nerve,, 
or of the inferior laryngeal, causes aphonia. The close relationship 
of the nervous supply of the sexual organs in the male to the in- 
nervation of the larynx is aptly illustrated in the unnatural voices of 
the castrated male sopranos. 



LARYNGEAL PARALYSIS. 491 

LARYNGEAL PARALYSIS. 

The laryngeal muscles may he paralyzed singly or in pairs, or 
several muscles may he affected simultaneously. The paralysis may 
be unilateral (Plate VIII) or bilateral^ affecting only one side or 
both. Anaesthesia of the laryngeal mucous membrane may exist as a 
complication. The paralysis may be of central origin, the disease 
being located in that part of the brain in which the laryngeal nerves 
have their origin, or it may be due to a disease in the course of the 
nerve-trunk. On the other hand, the lesion may be of a local char- 
acter, the muscles being affected, either primarily or secondarily, to 
some debilitating systemic malady. 

Pathology. — Cerebral causes of paralysis of the laryngeal mus- 
cles are : the gummata of syphilis, apoplexy, multiple sclerosis, tumors, 
etc. Diphtheria is one of the most frequent causes, aneurisms in the 
neck, tumors, progressive bulbar paralysis, hypertrophied glands, etc., 
are among the causes. The recurrent laryngeal nerve is subject to 
pressure from aneurism of the arch of the aorta, the left carotid, or 
the subclavian artery. Aneurism of the carotid, the subclavian, or 
the innominate artery on the right side may produce the same effect. 
These conditions result in unilateral paralysis, in which the epiglottis 
cannot be completely closed and there is loss of power to extend the 
vocal cord. When an aneurism or other tumor is large enough to 
occasion pressure on both recurrent laryngeal nerves bilateral paraly- 
sis results. 

The laryngeal muscles may become the seat of disease which, 
independently of any affection of the nerves, may impair or destroy 
their function. An extension of the inflammatory action from the 
mucous surfaces to the muscular tissue, with exudation and swelling, 
may produce a paretic condition of a transitory nature. Degenera- 
tive changes, such as atrophy of the muscular tissues, may occur to 
such an extent as to eventuate in muscular paralysis. 

Etiology, — Certain drugs and chemicals cause laryngeal motor 
paralysis, such as the following: Belladonna, opium, phosphorus, ar- 
senic, mercury, lead, and alcohol. Such diseases as diphtheria, rheu- 
matism, syphilis, anaemia, and inflammation of the adjacent areolar 
tissue and glands are causative conditions. 

When paralysis of the muscles of abduction — the posterior 
cricoarytenoid — occurs, the vocal cords lie in such constantly close 
relation to each other as to present a serious obstruction to respira- 
tion. The breathing is noisy and labored, and suffocation is immi- 



492 LARYNGEAL PARALYSIS. 

nent. The voice is not affected because of the action of the aryte- 
noideus muscle in approximating the vocal bands. When unilateral 
paralysis of the posterior cricoarytenoid muscle takes place there is 
no dyspnoea except on great exertion (Plate VIII). When both sides 
are affected it may be clue to brain disease in the region of the fourth 
ventricle or in the medulla affecting the pneumogastric and spinal 
accessory nerves. 

Paralysis of the muscles of adduction — the lateral cricoarytenoid 
— results in the vocal cords remaining in a condition of abduction, or 
separation from each other as far as possible. This occurs most fre- 
quently in hysteria and leaves no vestige of the voice. If this pa- 
ralysis is unilateral, whispering may be possible. 

When paralysis of the arytenoideus muscle happens the voice is 
very feeble or altogether lost. A triangular space between the vocal 
cords, behind the vocal processes, remains during phonation in conse- 
quence of the. loss of contractility of this muscle. 

Paralysis of the muscles of tension — the thyrocricoid and the 
thyro-arytenoid muscles — is not infrequent. Paralysis of the thyro- 
cricoid muscles leaves the vocal cords relaxed and uneven. They 
may be seen in contact with each other at irregular intervals and 
moving unnaturally, — depressed and elevated in the currents of air. 
The timbre of the voice is changed to a hoarse, monotonous. quality. 
The respiration may be more or less embarrassed. Paralysis of the 
thyro-arytenoid muscles prevents approximation of the vocal bands, 
especially at their centres, so that an elliptical aperture remains be- 
tween them. The voice is feeble, easily wearied, high-pitched, and 
husky. Inordinate use of the voice is the most frequent cause of this 
form of paralysis. 

All three forms of paralysis already described sometimes co-exist, 
— paralysis of abduction, adduction, and relaxation. This condition 
results in total suppression of the voice. The vocal bands remain 
jDassively half-way between abduction and adduction, or in the ca- 
daveric position. The usual causes are aneurism of the arch of the 
aorta, goitre, or disease of the oesophagus. If a brain disease were 
the cause, there would be loss of sensation and an erect epiglottis, 
indicative of paralysis of the superior laryngeal nerve. There may 
be unilateral paralysis of abduction, adduction, and relaxation, in 
which case but one vocal band assumes the cadaveric position (Plate 
VIII). In this form of paralysis the opposite and unaffected vocal 
cord may perforin vicarious function, so that the voice is but little 



TREATMENT OF LARYNGEAL PARALYSIS. 493 

roughened in quality; but, unless the power exists to draw the healthy 
cord beyond the median line to approximate its paralyzed fellow, the 
voice is seriously affected or destroyed. The effort of speaking soon 
tires the patient, and exertion causes labored respiration. 

Treatment. — The wide variation in the nature of the causes of 
laryngeal paralysis renders it impracticable, in a work of such an 
elementary character as this, to deal in detail with all of them. Le- 
sions of the nervous centres, of the circulatory system, of the apex 
of the lungs (especially of the right, a disease of which may cause 
pressure on the recurrent laryngeal nerve), enlargement of the glands 
of the neck, inflammation of the surrounding tissues and of the laryn- 
geal mucous membrane, tumors, and rheumatic and syphilitic con- 
ditions call for treatment adapted to each disease. Drug and chemi- 
cal poisoning must be met with antidotes, restorative measures, and 
removal of the cause. 

Strychnia, internally and hypodermically, to the degree of pro- 
ducing its physiological effects, is valuable. The faradic current, ap- 
plied to the interior and exterior of the larynx by the special laryn- 
geal electrode, is efficacious. If the mucous membrane of the larynx 
is sensitive it may have to be cocainized to admit of the application 
of the negative pole to the interior of the cavity. The current is 
applied by means of the kid-covered electrode, the tip of which must 
be moistened. By the aid of the laryngeal mirror this electrode is 
carried to the points that require the current, while the positive pole 
is applied to the front or sides of the exterior of the larynx. Com- 
pound electrodes are made so that both poles may be applied within 
the larynx. Their use is attended with more difficulty than presents 
in the introduction of the single electrode. The current is turned 
on for a few seconds at a time, and repeated frequently during a 
treatment, which is given on alternate clays. General tonic treat- 
ment and appropriate hygienic measures must be employed, accord- 
ins: to the necessities of each case. 



CHAPTEK XML 

DISEASES OF THE LARYNX, CONTINUED. 

TUBEECULOSIS OF THE LaEYNX. 

This is one of the most common of laryngeal affections and gen- 
erally proves fatal. It is seldom a primary disease, but usually is 
associated with the same condition in other organs, and in such cases 
is a secondary affection. 

Pathology. — The pathogenic principle of tuberculosis consists 
in a micro-organism, — the tubercle bacillus, — which gains entrance 
into the laryngeal tissues by becoming ingrafted upon an area of 
mucous membrane denuded of its epithelium. Within a few weeks 
after the development of primary laryngeal tuberculosis the lungs are 
invaded by the infection; so that we witness an intimate reciprocal 
relation between the various sections of the air-passages: laryngeal 
tuberculosis is most often a sequel of pulmonary tuberculosis, and 
consumption of the lungs may develop as a secondary manifestation 
of tubercular infection of the larynx. 

Generally the first changes observable in the larynx are: an un- 
natural paleness and tumefaction of the epiglottis (Plate VII), suc- 
ceeded by a superficial, ragged-edged ulceration on the posterior sur- 
face of the epiglottis, as seen in the mirror. Multiple ulcers soon 
form in other parts of the respiratory tract, extending below to in- 
volve the trachea, on the one hand, and upward into the pharynx, on 
the other. The ulcerative process may destroy the epiglottis. 

In acute tuberculosis of the larynx the development and course 
of the disease are often so rapid as to result fatally in the space of 
only a few weeks. This is known as miliary tuberculosis. These 
areas of miliary tubercle are easily made to bleed by pressing upon 
them. The mucosa and submucosa become Infiltrated, sometimes in- 
volving the mucous glands, and, as the disease advances, caseous de- 
generation occurs in the tubercles and adjacent tissues. In the acute 
form the membrane is seen to be congested, instead of pale, as is 
characteristic of the chronic form. 

A peculiarity of this disease is that it may stop short at the vocal 
cords, in its downward course from the pharynx and through the 

(494) 



TUBERCULOSIS OF THE LABYXX. 495 

larynx, and leave the cords unaffected, although the ventricular bands 
are involved even to the extent of so great tumefaction as to com- 
pletely hide the vocal cords. Sometimes, however, the latter become 
thickened to such a degree as to threaten suffocation. The processes 
of infiltration, caseation of the tubercles, fatty degeneration of the 
mucous glands, and breaking down and melting away of the mucous 
membrane over these tubercular areas proceed until the whole of the 
interior of the larynx may become involved. The destruction con- 
tinues until the cartilage itself becomes ulcerated, necrosed, and dis- 
integrated. As seen in Plate VII, the cartilages are thickened until 
the indentations separating the cartilages of Santorini and Wrisberg 
are obliterated. The resulting tumefaction appears in the shape of 
a pear. 

Etiology. — Tuberculosis of the larynx is usually consequent upon 
a pre-existing pulmonary consumption, although a primary lesion 
may occur in the larynx, as a result of the reception of the tubercle 
bacillus at a point on the mucous membrane where desquamation of 
the epithelium has occurred. Catarrhal affections, exposure to cold 
and wet and to an irritating atmosphere are predisposing causes. In 
pulmonary phthisis the lodgment of the tuberculous sputa from the 
lungs, as must occur in the larynx during expectoration, naturally 
tends to produce secondary points of inoculation. 

Heredity is not emphasized as strongly as it was in former years, 
but inherited tendencies and weakness and a positive predisposition 
to tuberculosis cannot be denied, in the light of actual clinical experi- 
ence. 

Symptomatology. — The visible pathological conditions already 
detailed need not be repeated. The sensations of the patient are very 
positive in their character. Pain is often a conspicuous symptom, 
especially during the act of swallowing. The voice shows early the 
presence of a laryngeal trouble, and the hoarseness and feebleness 
may progress until no sound can be uttered. 

When the posterior surface of the larynx is ulcerated the pain 
produced by swallowing may be excruciating. Sometimes the pain 
reaches to the ears, indicating ulceration of the pharyngo-epiglottic 
folds. 

Difficult respiration is not a common symptom, but may result 
from great swelling of the vocal cords, abscesses, or the presence of 
detached pieces of necrotic cartilages or of tumors. One of the most 
common features of this disease is cough. Patients complain of sen- 



496 TREATMENT OF TUBERCULOSIS OF THE LARYNX. 

sations of irritation, at first described as a tickling in the throat or 
larynx. At this early stage the cough is of a hacking character and 
without expectoration. When ulceration takes place or abscesses form, 
or when pulmonary tuberculosis is progressing, the cough is attended 
with expectoration. 

Diagnosis. — Generally an examination of the lungs will reveal the 
seat of the primary source of infection. As laryngeal tuberculosis 
may be associated with the same disease of the pharynx, inspection of 
the latter may disclose the nature of the malady. The laryngoscopic 
examination may bring to light the patches of miliary tubercle, but 
these tubercles cannot always be distinguished from hypertrophied 
racemose glands. 

In the early stages this disease is likely to be confounded with 
simple catarrh, but, as the latter yields readily to treatment and 
presents no symptoms of gravity parallel with those of localized or 
general tuberculosis, in view of the history of the case, habit of body, 
probable involvement of the lungs, joints, or other structures, and 
the laryngeal appearances, one should scarcely err. 

Prognosis. — Occasionally a case recovers; nearly all die. Acute 
tuberculosis of the larynx kills in a few weeks or months. In the 
secondary laryngeal tuberculosis consecutive to pulmonary consump- 
tion and characterized by caseation with acute symptoms, the disease 
proves fatal in from six to eighteen months. These cases may pursue 
a more chronic course and last from two to four years, or longer. It is 
a difficult matter to cause a tuberculous ulcer to heal, and, if it does, 
it usually breaks out again. 

From 10 to 40 per cent, of all patients with pulmonary tuber- 
culosis have this laryngeal complication, which shortens the duration 
of life. 

Treatment. — The treatment given in detail for tuberculosis of 
the pharynx is just as applicable here, and to avoid unnecessary rep- 
etition the reader is referred to that article for those remedies that 
are not given here. 

Lennox Browne (Journal of Laryngology, etc.) maintains that 
curettement is not absolutely necessary in this disease. Menthol, or 
menthol with iodol, in spray is best in the preulcerative stage. For 
pain he uses the ethereal solution of aristol in a spray. Morphia in- 
sufflations are used in hopeless cases only, but codeia largely, and 
cocaine before manipulations and in advanced dysphagia. Sprays 
are better than insufflations of powders. Excepting for relief of 



TBEATMEXT OF TUBERCULOSIS OF THE LAEYXX. 497 

acute dysphagia, lie prefers applications of the tincture-of -benzoin 
compound, tincture-of-eamphor compound, and tincture of bella- 
donna mixed with yelk of egg just before food. He employs lactic 
acid rubbed in with considerable force, but not employed previously 
to ulceration. The lactic acid is useless unless preceded by curette- 
ment once to about every four or six applications of the acid. He 
curettes for the removal of hyperplasia and to clear away the necrotic 
matter when the ulcers are large, and for converting all the ulcers into 
one. 

Desire recommends exalgin twice a day in doses of 4 grains as 
effective in relieving the difficulty of swallowing and pain. Wolfenden 
recommends feeding the patient while lying on his stomach while 
his head depends over the end of the couch, which is elevated so as 
to bring his feet higher than his head. He then takes liquid nour- 
ishment through a tube from the dish placed below his head. 

The antitubercular serum of Paul Paquin has been used in a 
considerable number of cases of tuberculosis with benefit. I have at 
this date, Xovember, 1897, reports from 369 cases that are of value, 
besides a large number that have been reported with such a degree 
of inexactness and indefiniteness that in giving the results it is neces- 
sary to eliminate them from the records. These ambiguous state- 
ments appear even more reassuring than the carefully-prepared ones. 
Paquin has reported 293 cases, with the following results: Recoveries 
that seem permanent, 57; considerably improved, 38; improved, 121; 
disappeared from observation, 41; deaths, 36. I have reports of 
76 cases to add to the above, giving the total results as follow: Re- 
coveries, 71; improved, 205; unimproved, 14; disappeared, 41; 
deaths, 38. 

Similar results from an oxygenated serum are being reported 
from San Francisco at the present time, but it is too early to speak 
judiciously regarding them. 

Since the beginning of the year 1898 unfavorable reports from 
the use of Koch's new tuberculin in tuberculosis and lupus of the 
throat and nose have emanated from Munich, Hamburg, and Prague, 
although some improvement, rather than any cure, was recorded in 
the Berlin clinics. 

When abscesses, growths, etc., produce so great obstruction to 
respiration as to threaten suffocation, tracheotomy must be done as 
a last resort. 



498 syphilis of the larynx. 

Syphilis of the Larynx. 

Pathology. — Syphilis of the larynx belongs almost always to the 
secondary or tertiary stage. It is first manifested by the appearance 
of a deep blush of congestion of the laryngeal mucous membrane, 
characterized by dryness. A little later the mucosa becomes swollen 
by serous infiltration, and this stage is soon followed by shallow, 
ulcerating patches (Plate VIII). The changes that take place in the 
larynx are similar to those occurring in the pharynx, but the results 
may be far more serious, owing to the diminished calibre of the 
larynx, which renders tumefaction and cicatricial contraction grave 
affairs. Mucous patches are likely to be found associated with the 
same lesions of the pharynx, and occur from three weeks to about 
three months or longer, following the initial sore. They are not 
found below the vocal cords, where there are no papillae. When the 
papillae are attacked they appear as small, red excrescences, swelling 
to the calibre of a small pea and obstructing respiration. From a 
rosy-red color they change to an ashy-gray surrounded by a zone of 
red. They may disappear by the process of absorption or ulceration. 
A sudden infiltration of the mucous and submucous tissues is an occa- 
sional occurrence, and in this situation is of serious import, since 
the resulting oedema may impede respiration to the point of strangula- 
tion. 

The tertiary stage is characterized by the presence of gummata, 
which become the seat of ulceration. When the erosions penetrate 
deeply into the submucosa the invasion of the blood-vessels gives rise 
to haemorrhages. Following these deep ulcerations are found white, 
corrugated, contracting cicatrices that lessen the lumen of the cavity 
by their contractions. Adhesions of adjoining denuded tissues pro- 
duce the same effect sometimes in a very short space of time. In 
this manner gross and obstructive deformities of the epiglottis, ven- 
tricular bands, and vocal cords give rise to a dangerous stenosis of the 
larynx. 

In the later stages of tertiary syphilis the laryngeal muscles and 
cartilages are invaded, with the result of producing paralysis, as well 
as ankylosis and destruction of the cartilages. 

Etiology. — Syphilis of the larynx is most often a tertiary lesion, 
occurring from three years to a much longer period after the initial 
ulcer. If it exist as a secondary manifestation, it follows the primary 
infection in a few weeks or months, the margin of the incubatory 
period in syphilis being very broad. These syphilitic invasions of 



SYPHILIS OF THE LARYNX. 499 

the larynx are very rarely primary, and they are more frequent in 
men than in women. 

Symptomatology. — As will he seen from the description of the 
pathological appearances in laryngoscopy, the first stage of syphilitic 
laryngitis closely resembles acute laryngitis of the simple variety. It 
may he impossible to distinguish early between the two unless a spe- 
cific history can be obtained. But in the syphilitic form of congestion 
or inflammation the rosy hue of the mucous membrane assumes a 
comparatively mottled arrangement, which is quite characteristic of 
this affection. These patches of redness are likely to be elevated 
above the surrounding surface and to show early evidences of be- 
ginning erosions of a superficial kind. In this period sensations of 
soreness, difficulty of swallowing, and pain appear. The voice begins 
to change in quality; the pitch is lowered, and a coarse timbre is 
imparted to it. A slight cough makes its appearance, occasioning 
little inconvenience, and accompanied by a muco-purulent expectora- 
tion. 

Inspection reveals the picture already described, resembling a 
simple laryngitis. The vocal cords may be involved sufficiently to 
show a congested condition (Plate VIII), which may be bilateral 
when one side of the larynx is involved to a greater extent than the 
other. Mucous patches are most frequently found on the epiglottis, 
in the interarytenoid space, and on the ventricular bands. They do 
not differ in appearances from those described as occurring in the 
pharynx. Papillomata are occasionally present, and can be seen as 
little, wart-like excrescences, or they may assume the appearance of 
yellowish pimples, nearly as large as a small pea. The mucous patches 
may disappear in a couple of weeks, when subjected to treatment, and 
leave a blushing area that gradually fades from sight. The condylo- 
mata may become absorbed or may ulcerate away. 

In the tertiary stage the epiglottis is most likely to be first in- 
vaded by the destructive process, ulcerations generally breaking out 
on the surface next the tongue or on its border. From this region 
they spread to the laryngeal cavity, differing from the erosions of 
the secondary stage in their invasion of the deeper layers of the mu- 
cous membrane, in the roughened surfaces due to granulation forma- 
tion, or to papillomata. The ulcers of the secondary stage are super- 
ficial patches; the ulcers of the tertiary period are deep-seated and 
destructive. 

Symmetrical bilateral lesions are characteristic of syphilis. When 



500 TREATMENT OF SYPHILIS OF THE LARYNX. 

an ulcer forms on one side of the larynx one may confidently expect 
to soon find its fellow situated in a corresponding area of the opposite 
side. The irregular, ulcerating surfaces are surrounded by a dark- 
red zone, and are bathed in a purulent discharge, which is expec- 
torated in abundance and imparts a foul stench to the breath. The 
cartilages break down and are thrown off in the expectoration. The 
epiglottis may disappear, and the particles of necrosed walls of the 
larynx may drop down into the chink of the glottis and threaten 
suffocation. When the deep erosions attack the walls of the blood- 
vessels and destroy their coats, serious haemorrhages may take place. 

Deformities due to swellings, cicatricial contractions, expulsion 
of parts of the cartilages, and muscular paralysis occur in the ter- 
tiary stage. Stenosis and consequent embarrassment of the respira- 
tion may then endanger life. 

Diagnosis. — This disease may be mistaken for tuberculosis, and 
in the early stage may be confounded with a simple catarrhal inflam- 
mation of the mucous membrane; but the latter yields readily to 
treatment, while the syphilitic disease progresses uninfluenced by any 
other than specific treatment. 

In tuberculosis serious constitutional disturbances are present, 
such as are not accompaniments of syphilis: fever, emaciation, etc. 
The areas of hyperemia that later become the seat of ulceration are 
paler and softer in tuberculosis than in syphilis. The ulcers of syph- 
ilis have more regular, clearly defined borders, and are deeper than 
in tuberculosis. The pain of the latter disease, especially in swallow- 
ing, causes great suffering, while it is not a prominent symptom of 
syphilis and may be absent altogether. The patient improves and 
gains in weight on specific treatment in syphilis, but grows worse in 
tuberculosis. The presence of pulmonary tubercular lesions will aid 
in clearing up the diagnosis. 

Prognosis. — This disease yields most brilliant results except in 
extreme cases of the tertiary type, in which great deformities and loss 
of structure and function occur. 

Treatment. — Constitutional remedies alone will often dissipate 
laryngeal syphilitic lesions without the introduction of local treat- 
ment. This disease, therefore, requires less mechanical skill in its 
management than tuberculosis and other affections of the larynx. 
In the early stages mercurials are indicated, while in the later periods 
the iodides are called for, or the mixture of the two, which is often 
more efficacious than the iodides alone. 



TREATMENT OF SYPHILIS OF THE LARYNX. 501 

The use of the voice, alcoholic stimulants, and tobacco must be 
interdicted, and in the secondary manifestation 1 / 16 grain, or even 
more, of the bichloride of mercury may be given thrice daily. If the 
green iodide is employed, 1 / c grain may be used. Inunctions of mer- 
curial ointment may be resorted to if the stomach reject internal 
treatment, a drachm being rubbed into the skin. In ulcerations a 
spray of carbolic acid and iodine in lavolin, 4-per-cent. solution, is 
useful when thrown into the larynx so as to bathe the ulcerated sur- 
faces. This has mildly anaesthetic and alterative effects and answers 
the purpose of a detergent and protective. 

In the tertiary stage the mixed treatment has given the best re- 
sults. I have generally prescribed the mercuric bichloride, 1 / 16 
grain, and the potassium iodide, 5 or 10 grains, to be taken three or 
four times a day in 1 drachm of syrup of sarsaparilla, well diluted. 
The doses are increased in size as tolerance will permit, care being 
taken that the stomach is not deranged by them. The ulcerations 
may require local treatment, such as has already been given under 
the heading of "Syphilis of the Pharynx. " J. Solis-Cohen J s favorite 
topical application consists of cupric sulphate in crystals or in solu- 
tion, or chromic acid, 1 part in 1 or 10 parts of water. Nosophen and 
aristol may be dusted over the ulcers with the throat powder-blower 
(Fig. 198). 

Paralyses usually yield to the constitutional treatment, but it 
may be advisable to employ electricity and strychnia. 

Contractions and tumefactions may occur sufficiently to cause 
strictures and stenosis of the larynx. If the interference with res- 
piration is considerable, the aponeurotic membrane and other ad- 
ventitious tissue must be incised or removed (Fig. 214), or they can 
be divided and destroyed by means of the galvanocautery. When ex- 
treme stenosis threatens suffocation, intubation or tracheotomy must 
be performed. Since the cicatricial tissue of syphilitic origin is little 
susceptible of dilatation, a tube may have to be worn permanently 
after tracheotomy. Schrotter has devised laryngeal dilators to be 
inserted at first by the surgeon and later by the patient. These are 
left in position as long as the patient can endure them, using sizes 
of increasing calibre. They are used daily to increase the lumen of 
the laryngeal aperture, taking from six to eighteen months to effect 
a permanent dilatation. 



CHAP-TEE XLIIL 
DISEASES OF THE LARYNX, CONCLUDED. 

TUMORS. 

For convenience of description, tumors of the larynx are con- 
ed 
tumors. 



sidered under two main headings, — "Innocent" and "Malignant 



Innocent Tumors. 

Benign, or non-malignant, tumors of the larynx arise as the 
result of various kinds of irritation, — such as inordinate use of the 
voice, great exposure to cold and wet weather, inhalation of air con- 
taining much dust, especially of a metallic nature, etc. 

PAPILLOMATA. 

Papillomata are more common than any other form of tumors 
of the larynx (Plate VIII) . They present widely-differing variations in 
size and physical appearances. They may be white or a light-red color, 
and the size of a bean or less, sessile and rough, single or multiple. 
Others resemble gray warts, springing from the vocal cord like little 
cones. These are most common in adult life. Children or young 
people are often subject to laryngeal papillomata, which assume a 
multiple form comparable to the raspberry or miniature cauliflower. 
They are rapidly regenerated after being removed. Indeed, all of 
these varieties may recur; but they may be very slow in returning, or 
they may not be reproduced at all. 

Papillomata develop, not only on the vocal cords, but on the 
ventricular bands, and on the aryepiglottic folds, and they may attain 
to such numbers or size as to occlude a view of the cords, interfere 
with respiration, and stifle the voice. A guarded prognosis must be 
given when a papillomatous growth is found on one side and above 
the cord, or upon its margin in elderly people, since it is suggestive 
of laryngeal cancer. 

FIBROMATA. 

Fibromata usually develop near the anterior extremity of the 
vocal cord (Plate VIII). These tumors vary from a gray to a deep- 
(502) 



PLATE VIII 



PLATE VIII. 



Figure 22. — Syphilitic infiltration of the arytenoid cartilages and the right 
vocal cord; gummata of the right half of the epiglottis. 

Figure 23.— Tertiary syphilitic ulceration of the epiglottis and the right aryt- 
enoid cartilage; great thickening and congestion of the epiglottis and of the aryt- 
enoid cartilages. 

Figure 24. — Pachydermia laryngis; the growth springing from the posterior 
portion of the left vocal cord, causing a corresponding depression in the right cord. 

Figure 25. — Pachydermia of the larynx; twin tumors springing from the poste- 
rior portions of the vocal cords; the convex surface of the left growth fits into a 
corresponding depression in the right. 

Figure 26. — Pachydermia laryngis located in the interarytenoid space. 

Figure 27. — Papilloma growing from the anterior portion of the right vocal 
cord, preventing close approximation of the cords in voice-production. 

Figure 28. — Papilloma of the left vocal cord, presenting an appearance sug- 
gestive of a raspberry. 

Figure 29. — Multiple papilloma of the larynx completely covering the vocal 
cords. 

Figure 30. — Fibroma of the right vocal cord producing hoarseness and, finally, 
aphonia. 

Figure 31. — Carcinoma of the larynx, ulceration and necrosis of the left aryt- 
enoid cartilage, and paralysis of the left vocal cord. 

Figure 32. — Unilateral paralysis of the adductors of the left vocal cord, as seen 
during an effort at voice-production. 

Figure 33.— Unilateral paralysis of the left abductor, as seen in forced inspira- 
tion. The left cord is in the cadaveric position. 



PLATE VIII 




27 





29 





PACHYDERMIA LARYXGIS. 503 

red color, and they may be attached by a broad base or by pedicles. 
They are generally solitary, and present a smooth surface, but when 
a large size is attained they may become lobnlated. Their size varies 
from that of a small pin-head to a pea, or, indeed, they may fill the 
larynx; but such an enormous development is seldom seen. When 
touched with an instrument they impart the feeling of a firm, dense 
tissue. Their removal is followed by more satisfactory results than 
obtain after operations on other tumors of the larynx, for they do 
not often reappear. 

PACHYDERMIA LARYXGIS. 

Virchow and Frankel were among the first to describe a thick- 
ening of the mucous membrane covering the free edges of the vocal 
cords and lining the interarytenoid space, and especially in the region 
of the vocal processes (Plate VIII). 

Pathology. — There is a great increase in the thickness of the 
epithelium, and in the number of papillae, and horny changes in the 
outer cells. The tendency is to the formation of oval tumors, and 
when they occur on the vocal cords there are frequently two seated 
opposite each other. In this case the apex of one fits into a depres- 
sion in its fellow. The interarytenoid pachydermia is not so often 
seen as the growths upon the cords. The color is whitish gray, or 
possibly pink. 

Etiology. — Pachydermia is found more often in middle-aged 
men than in women, and they are probably caused by excessive use 
of the voice, tobacco, and alcohol. 

Symptomatology. — There are huskiness of the voice, sensations 
akin to a foreign body, possibly dull aching, and even labored breath- 
ing and painful swallowing. The neoplasms may attain to so large 
a size as to suppress the voice. In such cases the tumors assume a 
pink color. 

Diagnosis. — The symptoms are generally much less pronounced 
than in malignant disease. The interarytenoid growth is suggestive 
of tubercular infiltration, but the latter is more clearly defined, is of 
a deeper-red color, and produces more disturbance than the former. 
Moreover, pachydermia more often occurs in the form of symmetrical, 
or twin, tumors on some part of the free margins of the vocal cords. 
The unilateral form of this tumor, known as singers nodule, might 
be mistaken for a fibroma. Pachydermia is found most frequently on 



501 LARYNGEAL TUMORS. 

the posterior portions of the vocal cords, while cancer occurs on the 
anterior parts generally. 

Prognosis. — The outlook is favorable to life, but unfavorable in 
respect to the voice, when the growths occur on the vocal cords. 
When they are situated in the interarytenoid space the vocal func- 
tions may not show impairment. 

Treatment. — Measures should be first addressed to the correction 
of any catarrhal conditions that may be present, along the lines already 
laid down in the previous pages. In addition to local treatment, potas- 
sium iodide should be administered in moderate doses. When the 
voice is affected, strong astringents, such as a 10-per-cent. solution of 
silver nitrate, may be applied, or the electric cautery may be resorted 
to. If the tumor is of sufficient size to permit grasping it with in- 
struments, it should be crushed by the biting-forceps (Fig. 214). 

In a discussion on this subject before the Twelfth International 
Medical Congress in Moscow, August, 1897, Heryng spoke of the 
operative treatment of the vocal cords affected by a pachydermatous 
condition resulting from repeated attacks of catarrh. He remarked 
that "it was not the beautiful pearly-white cords that produced the 
finest voices, this pearly whiteness often being produced by numerous 
layers of thickened epithelium. Some of the best singers had dis- 
tinctly red, catarrhal-looking vocal cords; for example, Jean de 
Keszke's vocal cords were slightly red before, and very red after, sing- 
ing. One should be in no hurry to treat a singer's larynx in any 
radical way." He especially warned young laryngologists to be ex- 
tremely careful in their dealings with singers. It is easy to under- 
stand why pachydermia is frequent among them. They are exposed 
by the nature of their calling to frequent catarrhal attacks; they are 
prevented from obtaining proper treatment for each attack; they are 
compelled to sing whether it prove detrimental to their voices or not; 
and, although overindulgence in eating, drinking, and smoking are 
destructive to singing voices, "nearly every singer smokes too much, 
eats too much, and drinks (alcoholic beverages) too much. By these 
means a slight catarrh or cold easily becomes chronic, and proceeds 
to produce pachydermia." (Medicine, March, 1898.) 

MISCELLANEOUS. 

Other very rare specimens of growths may be found in the larynx. 
Polypoid excrescences, such as mucous polypi, or myxomata, some- 
times make their appearance in the vicinity of the anterior com- 



LARYNGEAL TUMORS. 505 

missure. They are attached by peduncles, and have a pale or red, 
smooth surface. Occasionally the epiglottis is the seat of a cystic 
tumor which presents a regular, rounded surface. 

Vascular, fatty, and cartilaginous tumors are so very seldom met 
with as to require a description in exhaustive works only. The symp- 
tomatology and treatment are the same for these as for laryngeal 
tumors generally. 

Symptomatology. — The symptoms are those characteristic of ob- 
struction to respiration, phonation, and deglutition. Respiration is 
not interfered with in the early history of a laryngeal growth unless it 
is located in close proximity to the vocal bands or unless it is of rapid 
growth, so as to attain a large size and materially encroach upon the 
lumen of the respiratory space. Wjth the increase in the bulk of the 
tumor, difficulty in respiration increases until it may end in asphyxia, 
unless relief is afforded. The voice may not be impaired if the tumor 
is situated sufficiently above the vocal cords to prevent any embarrass- 
ment of their vibrations. Should the growth be located on one of the 
vocal cords it acts like a clamper, impeding the movements of the 
cord in response to the column of air, and, if it rest between the 
cords, it prevents their approximation and not only causes dysphonia, 
or difficulty in the production of the voice, but it changes its quality 
and interferes with respiration. The vocal bands then cannot be 
normally approximated, and the breathing-space between the cords is 
lessened in degree, according to the size and shape of the growths. 
Difficulty in swallowing occurs as a result of the location of the tumor 
where it prevents closure and perfect coaptation of the epiglottis over 
the entrance to the larynx. If it is seated upon the posterior surface 
of the epiglottis, as it presents in the laryngeal mirror, the same effect 
may be produced. Cough may or may not be a symptom, but it may 
be present as a result of the inability to evacuate easily the accumula- 
tions of mucus, which then act like a foreign body, or in case the 
tumor is of such a kind as to vibrate in the currents of air and thus 
produce a tickling or cough-provoking irritation. Patients with be- 
nign tumors seldom complain of suffering pain. 

Prognosis. — So far as the question of life is concerned, one is able 
to give a favorable prognosis in the case of an innocent laryngeal 
neoplasm. Should the growth reach such proportions as to render 
death imminent by asphyxia, tracheotomy will avert a fatal termina- 
tion. If the tumor be not removed by an endolaryngeal operation, 
thyrotomy in ay lie resorted to, although the effect on the voice is 



506 



TREATMENT OF LARYNGEAL TUMORS. 



better in endolaryngeal operations, more especially when the tumors 
are readily accessible and pedunculated. As has been already re- 
marked, there is a strong tendency to regeneration of the growths 
after operations for the removal of papillomata. 

Treatment. — There are numerous methods for the removal of 
tumors of the larynx. Forceps, knives, and curettes (Fig. 214) have 
been devised for this purpose. Snares, the galvanocautery, and caus- 
tics are in general use to effect the same results. 

When the growths have not attained a considerable size and are 
not easily engaged in an instrument, chemical caustics are applicable. 
Before any operative procedure the interior of the larynx should be 
anaesthetized with a 20-per-cent. solution of cocaine. Chromic acid, 
preferred by Jarvis, is fused into a bead of proper size and shape on 




Fig. 214. — Tobold's set of six forceps, knives, etc. 



the flexible applicator (Fig. 71) and accurately applied to the surface 
of the growth. Silver nitrate can be similarly employed, fused in the 
same manner on the platinum-wire loop of the applicator. 

In making applications of caustics, or in manipulating any in- 
struments in the larynx, the operation is done by the aid of the laryn- 
geal mirror, so that every movement and the relations of all the parts 
can be closely watched. It must not be forgotten that the movements 
of the instruments in the larynx are directly opposite to the move- 
ments as seen in the mirror, everything being reversed. The utmost 
care must be exercised, or injury will be inflicted on the surrounding 
tissues that will be, perhaps, far more serious than the original trouble. 

Lennox Browne prefers the snare for the removal of growths. 
Dundas Grant has devised guarded cutting-forceps that take as firm 



MALIGNANT TUMORS OF THE LARYXX. 50? 

a grip upon the tumor as Mackenzie's instruments. Much care must 
be exercised that a tumor once severed from its attachment does not 
drop back into the larynx as it is being removed. Evulsion of laryn- 
geal tumors is preferred by some operators. For this purpose the 
strong forceps of Mackenzie afford a firm grip upon the growths (Figs. 
199 and 215). These instruments are used without great difficulty if 
the larynx is properly anaesthetized. This is accomplished if the co- 
caine solution is applied two or three times at intervals of five min- 
utes. The benumbing effect of cocaine in the larynx is very transi- 
tory, not extending over ten minutes, so that operative measures must 
not be prolonged without renewed anaesthesia. 

When operating in the larynx, one ought always to have his 




Mackenzie's anteroposterior laryngeal forceps. 



tracheotomy instruments at hand, for instances have occurred in 
which spasm of the glottis has immediately followed the procedure, 
necessitating opening the larynx to prevent a fatal suffocation. 

Ephraim Cutter was the first to perform laryngotomy for the 
removal of a laryngeal tumor. This must sometimes be done when 
the growth cannot be extracted in the usual way. An incision is made 
into the angle of the thyroid cartilage, the tumor removed, and the 
wound closed. 

Malic xaxt Tumors. 

Malignant growths of the larynx are not uncommon. They may 
be classed as carcinomata and sarcomata. 



508 LARYNGEAL CANCER. 

CARCINOMATA. 

These are commonly known as cancers (Plate VIII), and are, by 
far, the most frequent of malignant growths in this locality. Bos- 
worth reported, as a result of a collective investigation of the subject, 
that, out of three hundred and thirty-four published cases of malig- 
nant growths, two hundred and four were cancers and one hundred 
and thirty were sarcomata. 

There is considerable variation in the nomenclature of this sub- 
ject. Browne treats of cancer under two headings: "Epithelioma" 
and "Alveolar Epithelioma" (adenoid, scirrhous, or encephaloicl can- 
cer). These growths may occur as primary diseases of the larynx or 
they may result from an extension to this organ from adjacent tissues. 

Pathology. — The existence of epithelioma cannot be determined 
positively by the mere evidence of a microscopic examination that 
there is a proliferation of epithelium and cell-nests. It is settled that 
the process is of a malignant character only when the epithelial pro- 
liferating process invades the underlying connective tissue, and its 
infiltrating nature is established. The disease more often originates 
on the ventricular bands than on the vocal cords. In the early stage 
of cancer the tissues present an hypergemic and indurated appearance, 
which gradually extends to the surrounding structures. The thick- 
ening increases irregularly until a more or less well-defined tumor 
results; the enveloping membrane softens, breaks down, and the stage 
of ulceration is established, with its wide-spread destruction of the 
parts involved. Excision of a deep portion of the growth may be 
made for a microscopic examination. 

Etiology. — Heredity is an important etiological factor, and any 
occupation or habit that excites a constant irritation of the tissues, 
according to Virchow, may result in converting an innocent neoplasm 
into a malignant growth. Cancers usually do not occur before the 
fortieth year. 

Symptomatology. — The effect upon speech and articulation will 
depend upon the situation of the tumor. If it belong to the intrinsic 
form,- — that is, if it attack the subglottic space, the vocal cords, the 
ventricles, or the ventricular bands, — the voice is more or less seriously 
affected. Should the growth be limited to the arytenoid cartilages, 
the sinus pyriformis, the aryepiglottic folds, or the epiglottis, thus 
constituting an extrinsic laryngeal neoplasm, the voice may not be 
markedly changed. When infiltration extends to include the laryngeal 
muscles, interfering with their functions, the voice is altered accord- 



LARYNGEAL CANCER. 509 

ing to the muscles affected. Hoarseness may exist from near the be- 
ginning of the growth, and later the voice may be entirely lost. 

In the intrinsic form not only the voice, but respiration, is em- 
barrassed. Cough may not be present until ulceration has occurred, 
when a purulent expectoration occurs. In deep erosions, necrotic 
tissue stained with blood and characterized by a very offensive odor 
appears in the sputa. In the final periods of the disease difficult deg- 
lutition is present, especially in the extrinsic variety of tumor. 

Pain, the label of malignant growths, is an invariable symptom. 
It is likely to radiate through the neck into the pharynx, and, as 
occurs in tuberculosis of the larynx, it extends to the ears. So con- 
stant and conspicuous a symptom is the involvement of the ears in 
pain that von Ziemssen considered it pathognomonic of laryngeal 
cancer. The general appearance of the patient after a long duration 
of the disease corresponds to the condition called by that classic 
alliterative term "cancerous cachexia." 

Inspection shows the location of the growth. At an early date 
only a thickened or nodular condition of the mucosa may appear, of 
a gray or deep-red color. When the epithelium is desquamated and 
the ulcerative process is established, a granular proliferation of the 
tissues springs up about the border of the erosion. Fungoid growths 
are seen sprouting from the surface of the ulcer, only to succumb 
to the necrotic process later. As the disease advances the destructive 
process becomes so great as to cause abscesses; the cartilages are at- 
tacked, and portions of necrosed cartilage are loosened and expecto- 
rated; haemorrhages occur; the breath is foul; the larynx becomes 
constricted, and, unless surgical interference be resorted to, death 
ensues. 

Diagnosis. — Laryngeal cancer is not always easily distinguished 
from other affections in which there is tumefaction or ulceration. 
In chronic hypertrophic laryngitis and in pachydermia laryngis the 
hyperaemia and thickening of the mucous membrane simulate the 
early stage of cancer, but in the former diseases we will note the ab- 
sence of pain, ulceration, infiltration of the cervical glands, and the 
microscopical appearances. However, it should not be overlooked 
that a microscopical examination of a section of a tumor may show 
that the portion removed is non-malignant, while it does not prove 
that the whole growth is benign. 

The author could cite repeated instances in which many careful 
microscopic examinations have been made by different bacteriolo- 



510 LARYNGEAL CANCER. 

gists, when their conclusions were not borne out by the ultimate 
clinical results. So frequently are the histological evidences, inter- 
preted by the microscope, negative in character, it is all the more 
incumbent on the clinician to exercise the utmost patience and skill 
in determining the differential diagnosis. 

In this connection it is interesting to recur to the discussion on 
this subject which took place at the meeting of the Twelfth Inter- 
national Congress, at Moscow, in August, 1897. Chiari reported 70 
cases of carcinoma laryngis occurring under his own observation. 
Comparing the clinical with the microscopic diagnosis, he maintained 
that, when the clinical evidences favored a diagnosis of cancer, a 
negative microscopic examination was not to be considered; whereas, 
positive microscopic evidences obtained by a thoroughly competent 
microscopist must outweigh clinical evidences to the contrary. 

Hajek claims that intrinsic and extrinsic carcinomata of the lar- 
ynx are to be put into two totally separate categories, the former being- 
much milder in its course than the latter, on account of the very 
poor supply of lymphatics to the larynx. Carcinoma on the poste- 
rior wall of the larynx is rare; when occurring at that situation it 
is difficult to diagnose. Pachydermia, as a rule, occurs on the poste- 
rior parts of the vocal cords, whereas cancer occurs on the anterior 
portions. Pachydermia is almost always bilateral, but cancer is uni- 
lateral. "The lazy, limited movement of the vocal cord, so much 
spoken of in cancer, is hardly a trustworthy symptom, because it is 
often absent in cancer and present in pachydermia. Much more 
valuable is the fact that pachydermia appears, on laryngeal examina- 
tion, to be a growth on the vocal cord, while a commencing carcinoma 
does not appear as a growth at all, but rather as an indefinite thick- 
ening of the cord itself, of which one cannot say where it begins and 
a healthy cord ends." (Medicine, Januar}^ 1898.) 

From papilloma, cancer may be distinguished by the facts that 
these warty growths occur in early life, as a rule, while carcinoma is 
usually found in persons past middle life. Papilloma is a more clearly 
defined tumor, while cancer presents an irregular infiltration and 
thickening. The cancerous cachexia and pain, also, are to be remem- 
bered as characteristically distinguishing features. If the cancer be 
extrinsic, enlargement of the lymphatic glands in the vicinity may be 
found. 

In tuberculosis of the larynx there are the characteristic cough, 
pulmonary complication, history of consumption, lighter color, and 



TREATMENT OE LABYXGEAL CANCER. 511 

less swelling of the tissues preceding ulceration. After ulceration 
sets in it is not likely to erode the tissues as deeply as cancer does. 
The absence of the bacillus of tuberculosis is only negative bacte- 
riological evidence, for the author has watched the destructive process 
do its deadly work through long, weary months to a fatal termination, 
while various microscopes and bacteriologists utterly failed to dis- 
cover a single bacillus. 

From syphilis it is sometimes difficult to distinguish epithelioma, 
especially from the gummatous stage of the former. Gummata, how- 
ever, ulcerate early in most cases. The question is simplified if the 
history be obtainable. Comparing the ulcerative stages of the two 
diseases, it is not an easy problem to solve. Xow comes the most 
reliable test. If it be syphilis, the exhibition of the iodides will cause 
a progressive clearing up of the symptoms, which, moreover, con- 
tinues; while, in the case of cancer, although there may be a per- 
ceptible improvement for a short time, this benefit is soon lost and 
the patient retrogresses in spite of the iodides. But the syphilitic 
increases in weight, and shows a general improvement as well as 
marked mitigation of the local symptoms. 

From innocent growths it may be exceedingly difficult to dif- 
ferentiate cancer in its early history, but the manifestations of the 
cancerous tumor are more pronounced than those of non-malignant 
neoplasms. The pain, age of the subject, and the appearances of the 
various tumors already described, taken with the history of the case, 
will form a group of facts that will tend to the formation of a cor- 
rect diagnosis. 

Prognosis. — According to Mackenzie, the average duration of 
the encephaloid cancer of the larynx is three years. Browne gives 
twelve months as the limit of life after removal of epithelioma. The 
results of tracheotomy are more favorable than those of thyrectomy 
or thyrotomy. Xo operation cures; starvation, haemorrhage, or as- 
phyxia ends life. 

Treatment. — By certain methods of treatment life may be pro- 
longed and rendered less torturesome. From a humanitarian point of 
view, if it were justifiable under any hopeless circumstances to relieve 
a fellow-being of his misery and despair by the merciful production of 
euthanasia, cancer of the larynx is that case. Death constantly stares 
his victim in the face, and, what is worse, like the burning coal in 
the eye of Cyclops, pain, in all its variations and refinements of 
torture, converts the patient's world into a chamber of horrors. Xo 






512 SARCOMATA OF THE LARYNX. 

words can depict the agonies of these coughing, choking, strangling 
sufferers. 

Local anaesthetics and anodynes must be added to detergents 
and antiseptics. Sprays of cocaine and morphia in ethereal solutions 
are indicated for the alleviation of pain. Aristol and iodoform may 
be used in the same manner. 

Chloroform and belladonna liniment may be employed for ex- 
ternal applications. Steam-inhalations containing conium and ben- 
zoin may prove grateful. 

One should bear in mind that there is always a possibility of a 
syphilitic taint, which would yield to specific treatment, and a trial 
of the effects of sodium or potassium iodide should be made. 

Operative measures may relieve the immediate suffering from im- 
pending suffocation, and may prolong life for several months. In 
October, 1895, Eoswell Park reported a case of total extirpation of 
the larynx for epithelioma. Fourteen weeks after the operation the 
patient presented himself at the clinic "the picture of health." Op- 
erations within the larynx are deprecated by some authorities: Browne 
and Newman. Oalvanocauterization produces only temporary benefit. 
Tracheotomy offers the greatest promise of relief from suffocation and 
may prolong life from two to four years. 

Chiarf's best results have been obtained from an operation, laryn- 
gofissure, when it is required to excise a vocal cord or false cord only. 
"This method, which is not attended by danger, insures a good voice 
and respiration, and it obviates the necessity of wearing a tube." It 
is only for intrinsic carcinoma that partial or total resection should 
be practiced. Ivrause maintains that the results from laryngofissure 
are not often permanent, recurrence taking place some time later. 
In fourteen of his cases treated by total extirpation of the larynx 
there was but a single death. In these cases the new method was 
employed in which the end of the trachea is stitched to the skin. 
This closes the communication of the trachea with the throat by 
stitching the mucous membrane, and by the use of tampons. 

SARCOMATA. 

These are very rare tumors of rapid growth, and attain to a large 
size. Their appearances differ widely, sometimes resembling fibromata 
or papillomata. Only a microscopical examination can give a positive 
diagnosis. They do not kill as quickly as epithelioma does, but are 
destructive of life sooner or later. They should be removed by some 



FOREIGN BODIES IX THE LARYNX. 513 

of the methods already described for the extirpation of other tumors. 
Max Toeplitz reports a case of chondrosarcoma cured by intralaryn- 
geal operation. 

Foreign Bodies in the Larynx. 

During inspiration while eating or in the act of laughing for- 
eign bodies are drawn near or into the larynx, where they find lodg- 
ment. Lefferts reported a ease in which a brass watch-ring became 
imbedded so as to rest astride the aryteno-epiglottic fold and ventric- 
ular band, where it remained four years. 

Symptomatology. — The presence of any foreign body in the 
larynx excites most violent coughing and symptoms of strangulation. 
If the body is of such a size and contour as not to completely fill up 
the lumen of the canal, breathing may proceed until the reflex spas- 
modic efforts at dislodgment succeed in expelling the body. When 
the entrance to the larynx or the glottis is completely obstructed, suf- 
focation may take place before relief can be obtained, the patient 
dying in a few minutes. Boluses of meat and other soft substances 
that apply themselves closely to the inequalities of the cavity are the 
most common causes of death from foreign bodies. But rough bodies 
may set up such an inflammation before their extraction that oedema 
of the larynx or pneumonia may result. 

If the body is coughed up, considerable soreness and pain may be 
experienced for a few days afterward. Small foreign particles some- 
times remain for a long time in the larynx before being thrown out 
by coughing or sneezing. They may give rise to an irritation that 
leads to a serious lesion of the mucosa. 

Treatment. — The finger can sometimes be made to reach and dis- 
lodge the body if it is in the vicinity of the entrance to the larynx. 
A common remedy is to slap the patient on the back of the shoulders 
just as he makes an expiratory effort. Gravity may be brought into 
play in case of a foreign body with some material weight. The pa- 
tient may be held with the feet upward and the head pendent while 
expulsive efforts are made by the patient. 

Sharp-pointed articles penetrate the walls of the larynx suffi- 
ciently to arrest their onward progress, and the coughing, retching, 
and gagging serve to force them farther into the tissues. All the 
sensitive area should be treated to a 20-per-cent. solution of cocaine, 
and by the aid of a mirror the object should be located. Then the 



514 FOREIGN BODIES IN THE LARYNX. 

laryngeal forceps of Tobold (Fig. 214) or Mackenzie (Figs. 199 and 
215) may be made to grasp and extract the offending invader. 

If failure attend the attempt to extract the foreign substance, 
and strangulation is impending, tracheotomy must be done without 
delay. If proper instruments are not at command, a pocket-knife 
will do, and retracting hooks can be improvised with safety-pins, 
hair-pins, or the like until sufficient conveniences can be supplied. 



CHAPTER XLIV. 

LIFE-INSURANCE AFFECTED BY DISEASES OF THE EAR, NOSE, 
AXD THROAT. 

Theee are certain diseases of the ear, nose, and throat that would 
unquestionably deter any competent examiner for life-insurance from 
accepting risks in which they were involved. Such diseases, for exam- 
ple, are lupus, carcinoma, cholesteatoma, and tuberculosis. Tertiary 
syphilis, especially when the middle ear or the larynx is invaded, 
would be a valid cause for rejection of a candidate for life-insurance. 
This disease, on the one hand, may invade the labyrinth and even the 
more vital structures in the cranial cavity, or, on the other, its ex- 
istence in the larynx threatens the deeper tissues, endangering life 
by strangulation from an exfoliated necrosed cartilage or by a final 
stricture of the larynx. 

There are other diseases in respect to which there may be an 
honest difference of opinion as to their vitiating effect upon the ap- 
plication for insurance, and it is more particularly such as require a 
special knowledge and practical experience that we will consider. 

The external ear is occasionally the seat of pathological condi- 
iions that are apparently innocent in their incipiency, although they 
pursue a steady course to the development of a malignant disease with 
a fatal termination. A person may complain of nothing extraordinary 
relative to the ear beyond insignificant sensations of uneasiness and 
itching at some point which is slightly more prominent than the sur- 
rounding surface. Close examination may reveal a little thickening 
of the integument, possibly an abrasion produced by scratching. 
These points are easily overlooked by one who is not alert to the fact 
that lupus and carcinoma have their beginnings in such unsuspicious 
symptoms. Moreover, the patient's habit of scratching a given point 
and the resulting irritation may, according to Yirchow, convert a 
benign neoplasm into a malignant growth. 

AVe may pass over the subject of acute inflammatory conditions, 
since no examiner would be expected to accept such risks. 

The effect of a chronic dry catarrhal inflammation of the middle 
ear on life-insurance is a question of considerable interest. Experience 
has demonstrated that persons who are afflicted with such a disease 

(515) 



516 LIFE-INSURANCE AND EAR, NOSE, AND THROAT DISEASES. 

generally enjoy immunity from acute inflammatory attacks, and from 
suppurating processes in the middle ear. We very rarely observe a 
case in which an acute inflammatory action or a suppurating process 
supervenes upon a chronic non-suppurative inflammation of long 
standing. But another important question relates to the possibility 
of life being shortened, not by the disease itself, but by accidents that 
are rendered more liable to occur by reason of the impaired hearing 
which the disease produces. Occasionally it happens that a person 
is run over by cars or other vehicles in consequence of an inability 
to hear their approach. There can be no sincere difference of opinion 
with respect to the greater liability to injury or death from such 
causes among those who suffer from a high degree of deafness; but 
many of this class are gifted with a compensating acuteness of vision 
and a quick, high order of intelligence which counterbalance their 
hearing-defect to a large extent. It is evident, then, that the ex- 
aminer should estimate, not only the amount of impaired hearing, 
but should also take into account the keenness of sight and the in- 
telligent alertness of the person. If he be dull mentally, slow to see, 
think, and act, he may be expected to become the easy victim of a 
careless driver or engineer; but if he possess an active muscular sys- 
tem well under the control of a vigorous mind, supplemented by nor- 
mal vision, he may be relied upon as being quite capable of taking 
care of himself. 

Furthermore, a distinction must be made between the hyper- 
trophic or secretive form of dry catarrh of the middle ear, and the 
adhesive or sclerotic form. Although the former may be but a pre- 
cursor of the latter, in itself it is a much milder disease and is sus- 
ceptible of far more brilliant results from treatment. One may have 
the first, or milder, form for many years without suffering the ex- 
tinction of a large proportion of his hearing; but sclerosis causes a 
great loss of the hearing power. 

Chronic suppurative inflammation of the middle ear in an ap- 
plicant for life-insurance, aside from the resulting deafness, is a 
subject that cannot be lightly passed over. Examiners appear to ex- 
ercise especial care in such cases. The author has observed repeatedly 
that life-insurance examiners have insisted that persons with dis- 
charging ears must have the suppuration cured before their applica- 
tions would be accepted. At the present time a patient has just 
complied with an insurance examiner's requirement that he present a 
statement from the writer certifying that the suppuration of his mid- 



LIFE-INSURANCE AND EAR, NOSE, AND THROAT DISEASES. 517 

die ear had been cured, notwithstanding the fact that it had ceased 
a year ago, and the ear had remained well ever since. 

In another instance an examiner refused to accept an applicant 
for life-insurance because he had a chronic suppuration of the middle 
ear, but stated that the application would be favorably acted upon if 
the ear were cured. Examination revealed granulations, necrosed 
ossicles, and carious tympanic walls, causing a foul discharge. The 
writer removed the granulations and ossicles and curetted the carious 
bone; a cure resulted and the patient secured his insurance-policy. 
That the insurance examiner's judgment was sound is evidenced by 
the fact that such, cases tend strongly toward mastoid involvement, 
and that the patient still remains well after the lapse of six years. 
These instances are fair examples of the care and intelligence mani- 
fested by the medical examiners in protecting their companies against 
loss. 

On account of the vast possibilities of damage from suppuration 
of the middle ear it becomes a matter of the highest importance to 
the insurance companies. While the disease is easily curable if 
treated properly in its early stages, if neglected it not only jeopards 
the general health, but imperils life itself. The mucous membrane 
lining the tympanic cavity, which is the structure inflamed, serves 
the double purpose of a mucous lining of this cavity and also of a peri- 
osteum. Therefore, it is so closely related to the bone that the latter 
is prone to become involved in the inflammatory process. The pneu- 
matic spaces of the mastoid process are lined by mucous membrane, 
which is a continuation of the membrane lining the middle ear; 
hence by continuity the inflammation extends from the tympanic 
attic through the aditus ad antrum into the mastoid antrum and cells. 
It is probable, in view of the relations of these cavities to each other, 
that whenever there is pus in the middle ear there is pus in the mastoid 
antrum also. 

Having in mind the conditions just described, it is not difficult to 
comprehend the .far-reaching consequences of a suppurative inflam- 
mation of the middle ear and the mastoid process. The pus, break- 
ing through the confines of the softened bone upward through the 
roof of the tympanic cavity, reaches the middle cranial fossa, pro- 
ducing a subdural or cerebral abscess or meningitis; breaking forward 
it forms a retropharyngeal abscess, which may break suddenly into 
the pharynx and fill the larynx with pus, producing strangulation; 
breaking downward it may burrow beneath the deeper layer of the 



518 LIFE-INSURANCE AND EAR, NOSE, AND THROAT DISEASES. 

muscles of the neck until it reaches the thoracic cavity; breaking 
backward from the mastoid cells, the pus empties into the posterior 
cranial fossa or into the lateral sinus. In the latter event pyaemia 
and phlebitis and thrombosis of the sinus may result. Without prompt 
and skillful surgical interference the fatal character of these condi- 
tions need not be dwelt upon. 

That it is well worth the while for medical examiners for life- 
insurance companies to attach sufficient importance to diseases of the 
ear is aptly illustrated by the experience of J. Morrison Eay (The 
Laryngoscope, August, 1897), who reported that out of 350 ear cases 
treated during the preceding year there were 6 fatal cases following 
suppuration of the middle ear. 

Diseases of the nose do not often prove fatal. Lupus, syphilis, 
and tuberculosis of this member are generally secondary to the oc- 
currence of these diseases in other locations. Carcinoma and sar- 
coma are rare in this part of the economy, and the examiner is not 
very likely to find causes here for the rejection of an applicant, un- 
less they are merely associated with the same causes in adjacent 
structures. However, one should be slow to accept an applicant who 
has a purulent discharge from his nose while such discharge con- 
tinues, since it might be the result of a purulent inflammation of the 
ethmoid cells or the frontal sinuses, which are in close relation to 
the meninges of the brain; or it might indicate empyaema of the 
maxillary antrum. 

If an applicant be subject to frequently-recurring attacks of sore 
throat, especially every spring and fall, it should suggest rheumatic 
sore throat, and a possible rheumatic heart affection. The throat 
ought to be inspected for tubercular, syphilitic, or cancerous lesions; 
and one should not forget that the ravages of syphilis in the throat 
may reach an appalling extent without the patient complaining much 
of pain, and that the tonsils are sometimes the portal of entrance of 
tubercle bacilli into the system. 

The larynx is often the seat of tubercular manifestations, but 
these are so often secondary to pulmonary infection that they are quite 
likely to be suggested by an examination of the lungs. But one must 
not be thrown off his guard by this fact, for instances of primary 
laryngeal tuberculosis are not infrequent, and the larynx should be 
examined in every case in which hoarseness, difficulty of deglutition, 
and soreness in the region of the throat are found. The existence of 
tumefaction or ulceration in the larynx is sufficient cause for either 



LIFE-INSURANCE AXD EAR, NOSE, AXD THROAT DISEASES. 519 

rejecting the applicant or for holding his application without action 
until the abnormal condition is corrected or shown to be innocent 
beyond a reasonable doubt. A course of the iodides may demonstrate 
that the lesion is syphilitic and in a curable stage, or it may reveal a 
tubercular or carcinomatous incurable disease. Even in this test 
one may be easily deceived unless he remembers that carcinoma may 
improve temporarily under the iodides; but the improvement is transi- 
tory only, and is lost as the case progresses, while in syphilis the 
benefit remains and increases with a marked betterment of the general 
health. 

There is a common belief among those who are not well read in 
medical matters that the existence of a catarrhal condition of the 
upper respiratory tract is necessarily a forerunner of grave lung le- 
sions. This fallacious notion is propagated with cunning zeal by the 
advertising medical charlatans for commercial reasons. The sug- 
gestiveness and plausibility of the idea render its exploitation an easy 
and profitable source of practice. They find the public mind ready 
to accept the belief that a catarrh of the nose and throat is almost 
certain to eventuate in consumption of the lungs. 

There is enough of the element of truth in such notions to be 
useful to the honorable practitioner, and to be susceptible of gross 
abuse at the hands of the mountebank. Certainly there is more likeli- 
hood of a bronchitis or pneumonia occurring in a person of a pro- 
nounced catarrhal type than in one who "never takes cold." So, too, 
there is more liability of finding a rheumatic lesion of the heart in 
one who is subject to attacks of rheumatic laryngitis or pharyngitis. 
Indeed, there are subjects in whom a severe attack of pharyngitis or 
laryngitis almost invariably either terminates in bronchitis or evinces 
a very strong tendency to do so. A uric-acicl diathesis should be 
looked for and corrected if found in applicants for life-insurance. 
Inquiries ought to be made with reference to their being subject to 
even slight onsets of rheumatism, neuralgia, migraine, sore throat, or 
symptoms of gout. The possibility of the development of angina 
pectoris should not be overlooked, since it is the result of uricacid- 
a?mia; and, besides the aids already suggested as afforded by the con- 
dition of the upper respiratory tract, the examiner should be in- 
fluenced by the evidence of hay fever and asthma, which are distinctly 
neuropathic diseases of a gouty origin. 



APPENDIX. 



REMEDIES. 



Speats. 

Lavolin: a liquefied vaselin with- 
out color, taste,, odor, or irritating 
properties. 

Benzoinol: a product similar to 
lavolin, with the addition of benzoin. 

Camphor-menthol, pure: the liquid 
product resulting from bringing to- 
gether equal parts of camphor-gum 
and menthol crystals without heat 
(C 10 H ls O). 

Micrazotol contains boroglvcerid, 
eucalyptol, thymol, resorcin, menthol, 
and benzoic acid. (Acid reaction.) 

Listerin contains the essential anti- 
septic constituents of thyme, eucalyp- 
tus, baptisia, gaultheria, and mentha 
arvensis in combination. Each flui- 
drachni also contains two grains of re- 
fined and purified benzoboric acid. 

Pasteurin contains the active prin- 
ciples of cassia zelanicum {Lauracece), 
eucalyptus (Myrtacece) , gaultheria 
(Ericacece), menthol combined with 
boroglvcerid, and 0.3 per cent, of 
formaldehyd. (Acid reaction.) 

Formolid contains formaldehyd, ace- 
tanilid, boroglvcerid, benzoborate of 
sodium, eucalyptol, thymol, menthol, 
oil of gaultheria, witch-hazel, and 
alcohol. (Acid reaction.) 

Borolyptol consists of 5 per cent, 
of acetoboroglycerid, 2 per cent, of 
formaldehyd, in combination with the 
active antiseptic constituent of pinus 
pumilio, eucalyptus, myrrh, storax, 
and benzoin. (Acid reaction.) 

Glycothymolin contains sodium, 
boric acid, benzoin, salicylic acid, 
eucalyptol. thymolin. menthol, and 
pine. (Alkaline reaction.) ' 



B Camphor-mentholis, 3 per cent. 
Lavolinis, 97 per cent. — M. 

I£ Camphor-mentholis, 5 per cent. 
Lavolinis, 95 per cent. — M. 

I£ Camphor-mentholis, 10 per cent. 
Lavolinis, 90 per cent. — M. 

B> Olei cubebae, 4 per cent. 
Benzoinolis, 96 per cent. — M. 

R. Camphor-mentholis, 10 per cent. 
Olei cubebse, 90 per cent. — M. 

R. Eucalyptolis, 3 per cent. 
Olei picis liquidse, 3 per cent. 
Lavolinis, 94 per cent. — M. 

— M. R. Brown. 



R^ Salolis, 4 per cent. 
Mentholis, 4 per cent. 
Lavolinis, 92 per cent.- 



-M. 



R. Olei eucalypti, 1 per cent. 
Thymolis, 1 per cent. 
Mentholis, 3 per cent. 
Olei gaultherise, 1 per cent. 
Lavolinis, 94 per cent. — M. 

R. Calendulse, 5 per cent. 

Hamamelidis, 5 par cent. 

Lavolinis. 90 per cent. — M. 
Prepared from the flowers of calen- 
dula and the leaves of hamamelis by 
percolation (Truax. Greene & Com- 
pany). 

R> Thymolis, gr. x. 
Eucalyptolis, gr. xx. 
Mentholis, gr. xxx. 
Olei cubebae, gr. xl. 
Benzoinolis, §iv. 
Olei rosse. q. s. — M. 

- — O. B. Douglas. 

R> Eucalyptolis, 4 per cent. 
Benzoinolis, 96 per cent.— M. 



(521) 



522 



APPEXDIX REMEDIES. 



P* Mentholis, 3 per cent. 

Lavolinis, 97 per cent. — M. 

P* Olei pini sylvestris, 4 per cent. 
Benzoinolis, 96 per cent. — M. 

P* Iodini, 

Acidi carbolici, of each, gr. ij. 
Benzoinolis, §j. — M. 

P* Iodoformi, gr. ij. 
Benzoinolis, %}.- — M. 

P* Olei pini sylvestris, min. xxx. 
Olei eucalypti, 3j. 
Olei gaultherise, min. xxx. 
Camphor-mentholis, 3j. 
Terebinthinse Canadensis, 3j. 
Tincturse benzoini, q. s. ad %iv. — M. 

P* Iodini, gr. xx. 

Acidi carbolici, gr. xij. 
Camphor-mentholis, 3j. 
Lavolinis, q. s. ad §iv. — M. 

P* Calendula?, 4 per cent. 

Hamamelidis, 8 per cent. 

Pini strobi, 8 per cent. 

Lavolinis, 80 per cent. — M. 
Infusion of the flowers of calendula 
and the leaves of hamamelis with lav- 
olin. 

IJ Salolis, 3 per cent. 

Olei gaultherise, 4 per cent. 
Thymolis, 3 per cent. 
Benzoinolis, 90 per cent. — M. 



IJ Aristolis. 10 x 

Mentholis. 3 per cent. 
Benzoinolis 



Aristolis, 10 per cent. 
Mentholis. 3 per cent. 

"7 per cent. — M. 



IJ Aristolis, 5 per cent, 
Mentholis, 8 per cent, 
Benzoinolis, 87 per cent. — M. 

IJ Creasoti, 4 per cent. 

Acidi carbolici, 3 per cent. 
Olei picis liquidse, 3 per cent. 
Olei gaultherise, 4 per cent. 
Benzoinolis, 86 per cent. — M. 

IJ Acidi borici, 

Sodii bicarbonatis, 
Sodii chloridi, of each, 3ij. 
Glycerini, 3iij. 
Aquse rosse, %\v. 
Aquse, q. s. ad Oj. 
M. Filter. 



IJ Camphor-mentholis, 3 per cent. 
Olei pini sylvestris, 2 per cent. 
Eucalyptolis, 1 per cent. 
Benzoinolis, 94 per cent, — M. 

IJ Sodii chloridi, 3j. 

Sodii phosphatis, gr. ij. 

Sodii sulphatis, gr. xij. 

Potassii sulphatis, gr. ij. 

Potassii chloridi, 

Potassii phosphatis, of each, gr. iij. 

Mentholis, gr. j. 

Glycerini, 3iij. 

Aquse, q. s. ad Oj. — M. 

IJ Acidi tannici, gr. xl. 
Acidi gallici, gr. xx. 
Sodii bicarbonatis, 3ss. 
Aquse, Oj. — M. 

— Sajous. 

Bi Sodii chloridi, 
Sodii bicarbonatis, 
Sodii biboratis, of each, 3j. 
Aquas, Oj. — M. 

P* Sodii biboratis, 

Sodii bicarbonatis, of each, 3ij. 
Acidi carbolici, gr. xlviij. 
Glycerini, 3iiiss. 
Aquse, q. s. ad Oj. — M. 
(Dobell's solution.) 

F* Sodii biboratis, 

Sodii bicarbonatis, of each, §j 
Sodii benzo al_ 

Sodii salicyj^ps, of each, gr. xx. 
Eucalypt( 

ThymolJdB^ each. gr. x. 
Menthd^Pgr. v. 
Olei gaultherise, gtt. vj. 
Glycerini, gviiiss. 
Afcoholis, §ij. 
Aquse, q. s. ad Oxvj. — M. 
( Seller's solution. ) 

F* Acidi carbolici, gr, xx. 
Sodii boratis, 3j. 
Sodii bicarbonatis, 3j. 
Glycerini, 

Aquse rosse, of each, §j. 
Aquse, q. s. ad Oj. — M. 

— Leffert 



F* Zinci sulphatis, gr. xv. 
Thymolis, gr. V 3 . 
Alcoholis, 

Glycerini, of each, §iss. 
Aquse menthse piperitae, §x. — M- 



APPENDIX — REMEDIES. 



523 



IJ Pulveris aluminis, gr. v-xxx. 
Aquae, 3j- — M. 

— J. Solis-Cohen. 

IJ Antinosinae, gr. v. 
Aquae, gj. — M. 

IJ Antipyrinae, gr. xv. 
Aquae, 5j.— M. 

IJ Aristolis, 5-10 per cent. 
iEtheris, 95-90 per cent. 
M. Signa: Spray for tulerculous 
ulcers. 

IJ Morphiae sulphatis, gr. iv. 

Acidi tannici, 

Acidi carbolici, of each, gr. xxx. 

Aquae destillatae, of each, §ss. 
M. Signa: Spray for tubercular 
ulcers. 

IJ Sodii boratis, gr. v. 
Aquae rosse, §j. — M. 



Steam-inhalations. 
Infusion of opium, 3i-Oj. 

Infusion of belladonna, 3i-Oj. 

Infusion of hyos8yamus, 3i-Oj. 

Infwwen of coniuniv 5i-Oi. 

m. 

Compound tincture ^^benzoin, a 
teaspoonful to the pint of hot water. 

Pure camphor-menthol, gtt. x to the 
pint. 

Glycerinum acidum carbolicum, a | 
teaspoonful to the pint. 

IJ Glycerini, §j. 
Aquae calcis, Siij- 
M. Signa: Use in a steam-atom- 
izer. 

IJ Acidi carbolici, 

Zinci sulphocarbolatis, of each, 3j. 

Glycerini, Bj- 

Aquae, q. s. ad Biv. 
M. Signa: Use in a steam-atom- 
izer. 



Antiseptic and Astringent 
Solutions, etc. 

IJ Acidi borici, gr. xx. 
Aquae rosae, Sj. — M. 
(For the ear.) 

IJ Acidi borici, gr. x. 

Aquae destillatae, §j. — M. 

(For the eye.) 

1$. Zinci sulphatis, gr. ij. 
Acidi borici, gr. x. 
Aquae destillatae, Sj- — M. 
(For the eye.) 

1$. Zinci sulphatis, gr. viij. 
Acidi carbolici, gr. viij. 
Glycerini, 3j. 
Aquae, §ij. — M. 
(Ear-lotion.) 

IJ Acidi borici, gr. xx. 
Alcoholis, gj. — M. 
(For the ear when granulations are 

present. ) 

IJ Sodii bicarbonatis, gr. xx. 
Glycerini, 3ij. 
Aquae, 3vj. 
M. Signa: Use (warm) in the ear 
to soften cerumen. 

IJ Acidi borici, gr. xv. 
Aquae rosae, Bj- — M. 

IJ Iodoformi, 20 per cent. 
Alcoholis, 80 per cent. — M. 

Hydrargyri bichloridi, q. s. ad 1- 
5000 in aquam. 

IJ Hydrargyri bichloridi, gr. j. 
Aquae cinnamomi. Bx. 
M. Filter. 

IJ Hydrargyri chloridi corrosivi, 3j. 

Acidi tartarici, 3v. 

Aquae, q. s. ad Siv. 
M. Signa: Ounce ss ad Oj aquae 
(1 to 1000). 

IJ Hydrargyri chloridi corrosivi, 
Sodii chloridi, of each, 3j. 
Aquae, q. s. ad 3j. 
M. Signa: Drachm j ad Oj aquae 

(1 to 1000). 



524 



APPENDIX REMEDIES. 



B Hydrargyri chloridi corrosivi, 3j. 

Ammonii chloridi, gr. xxxij. 

Aquae, q. s. ad 3j- 
M. Signa: Drachm j ad Oj aquas 
(1 to 1000). 

I£ Acidi carbolici, 3vj. 
Aquas, q. s. ad Oj. — M. 

I£ Acidi carbolici, 3j. 
Olei olivae, 3x. 
M. Signa: Carbolized oil. 

Hydrozone: a 30-volume dioxide 
(peroxide) of hydrogen; H 2 2 . 

Glycozone, a chemically-pure, anhy- 
drous glycerin saturated with ozone- 
gas at 0° C. ; powerful non- toxic, 
non-irritating germicide. 

I£ Creolinis, §j. 

Signa: Drachm i-vj ad Oj aquae. — 
Esmarch. 

I£ Acidi borici, 3iv. 
Aquae destillatae, Oj. 
M. Signa: Saturated solution. 

P* Potassii permanganatis, 3ij. 
Aquae, Oj. — M. 

Py Acidi salicylici, 3ss. 
Boracis, gr. xx. 
Aquae, Oj. — M. 
(For ozaena.) 

P* Aluminis, 3j. 

Acidi carboiici, gr. viij. 
Glycerini, §j. 
Aquae destillatae, Svij. 
M. Filter. 

IJ. Potassii chloratis, 3j. 
Aquae cinnamomi, Bviij. 
M. Filter. 



P* Potassii chloratis, 3j. 
Extracti hamamelidis, Sj. 
Aquae destillatae, §v. 
M. Filter. 



F* Tincturae ferri chloridi, Sj. 
Glycerini, §j. 
Aquae destillatae, 5vj. 
M. Filter. 



Px Sodii bicarbonatis, 1 per cent. 
Aquae, 99 per cent. 
M. Signa: Use for boiling instru- 
ments (to prevent corrosion). 

P* Acidi carbolici, 5 per cent. 
Aquae, 95 per cent. 
M. Solution for disinfecting instru- 
ments. 



Gargles. 



-M. 



P* Boracis, 3ij. 

Acidi carbolici, gr. xvj. 

Glycerini, 3ij. 

Aquae rosae, q. s. ad 5 viij . 

Pp Aluminis exsicc, 3j. 
Aquae rosae, Sviij. — M. 



P* Aluminis, 

Potassii bromidi, of each, 4 per 

cent. 
Aquae, 92 per cent. 
M. Signa: Gargle. 

P* Potassii chloratis, 3iv. 

Or 
P* Potassii bromidi, 3iv. 

Dissolve in a pint of nure water and 
gargle. 

P* Boracis, 

Potassii chloratis, of each, 3iv. 
Potassii carbonatis, 3vj. 
Sodii chloridi, §ij. 
Aquae, q. s. ad Oj. — M. 



Solutions foe Injecting into the 
Middle Ear Through the Eu- 
stachian Tube. 

Pilocarpine hydrochlorate, 2-per- 
cent, solution. 

Six or 8 drops to be injected 
through the Eustachian catheter. 

F* Sodii bicarbonatis, gr. x. 
Aquae, Bj.— M. 

F* Potassii iodidi gr. v. 
Aquae, 3j— M. 



/ 



APPEXDIX REMEDIES. 



525 



1$. Camphor-mentholis, 3 per cent. 
Lavolinis, 97 per cent. — M. 



Pigments. 



F* Aeidi tannici, gr. x-xxx. 
Acidi salicylici, gr. v. 
Glycerini, 3ij. 
Aquae destillatse, 5vj. — M. 

P* Aluminis. gr. x. 
Glycerini. 3ij. 
Aquae destillatae, 3vj. — M. 

P* Zinci sulphatis, gr. v. 
Glycerini, 3ij. 
Aquae destillatae, 3vj. — M. 

P* Zinci ehloridi, gr. x-1. 
Glycerini, 
Aquae destillatae, of each, 3iv. — M. 

F* Cupri sulphatis, gr. x. 
Glycerini, 3ij. 
Aquae destillatae, 3vj. — M. 

F* Iodoformi. 3j. 
Collodii, 5x.— M. 

( Iodof orm-collodion. ) 

— Ktjster. 

P^ Iodoformi. 3j. 
^theris, gj.— M. 
( Iodof orm-ether.) 

P* Iodoformi, gr. xxx. 
JEtheris, §ss. 

Aquae destillatae, q. s. ad §j. — M. 
(Iodof orm-ether.) 

— Xussbatjm. 

F* Glycerini acidi carbolici, 3ij. 
Glycerini acidi tannici, §ij. — M. 

F* Acidi carbolici, 12 per cent. 
Glycerini, 88 per cent. — M. 

Glycerinum acidum tannicum. 

F* Olei eucalypti, 

Acidi carbolici, of each, %]. 
Terebinthinae, §viij . — M. 

F* Guaiacolis, §ss. 
Glycerini, Sss. — M. 



P* Morphiae sulphatis, gr. iv. 
Acidi carbolici, gr. xxx. 
Glycerini, Sj- — M. 

F* Morphiae sulphatis, gr. iv. 
Acidi carbolici, gr. xxx. 
Acidi tannici, gr. xxx. 
Glycerini, gj. — M. 

F* Argenti nitratis, gr. xl. 
Aquae, gj.— M. 

F* Argenti nitratis, gr. x. 
Aquae, Zj.—^SL 

P* Creasoti. 2 per cent. 

Mentholis, 10 per cent. 

Lavolinis, 88 per cent. 
M. Signa: Apply to tubercular 
ulcers. 

Acetic acid, applied to tubercular 
ulcers. At first it should be used in 
a solution of 20 to 40 per cent., gradu- 
ally increasing to 100 per cent. 

P*. Creasoti, gr. x. 

Mentholis, 3j. 

Lavolinis, §j. 
M. Signa: Apply to tuberculous 
ulcers. 

Tincture of iodine. 

P* Plumbi acetatis, gr. v. 
Aquae, Bj- 
M. Signa: For syphilitic throat. 

P* Zinci ehloridi, gr. xx. 
Aquae, I]. 
M. Signa: For syphilitic throat. 

P* Cupri sulphatis, gr. xv. 
Aquae, gj. 
M. Signa: For syphilitic throat. 

Pyoktanin. 

Sulphocalcin, either diluted or full 
strength, for dissolving false mem- 
branes. 



Px. Potassii permanganatis, gr. xxx. 
Aquae, Sj- — M. 

(Antiseptic, and solvent of false 
membranes.) 



526 



APPENDIX REMEDIES. 



Lactic acid, applied locally by in- 
halation or by a cotton swab. (A 
solvent of false membranes.) 

I£ Acidi carbolici, gtt. xx. 

Liquoris ferri subsulphatis, 3iij. 
Glycerini, gj. 
Aquae destillatse, §ij. — M. 
(Local application for diphtheria.) 

B Alcoholis, 60 per cent. 
Toluolis, 36 per cent. 
Liquoris ferri chloridi, 4 per cent. 

— M. 
(Loffler's formula for the local treat- 
ment of diphtheria. On account of 
the pain this solution produced, 
Loffler added to this 20 per cent, of 
menthol. ) 



COTJNTER-IRR T TANTS AND LINIMENTS. 

Cantharidal collodion. 

Essential oil of mustard. 

Tincture of iodine. 

1$ Linimenti saponis, 

Linimenti camphoris compositi, of 
each, §j. — M. 

1$. Linimenti belladonna?, 

Linimenti opii, of each, 3iv. — M. 

Bi Linimenti chloroformi, 
Linimenti aconiti, 
Linimenti belladonnas, 
Linimenti opii, of each, 3iv. 
Linimenti saponis, §j. — M. 

P* Tincturse Valeriana?, 3ij. 
iEtheris sulphurici, 3j. 
Glycerini, 3xij. — M. 

F, Olei tiglii, 3ij. 
Chloroformi, 3ij. 
Aquse ammonii fortioris, Sj- 
Olei sesami, giij. 
M. Signa: Apply on cotton. 



Ointments. 



Vaselin, petrolatum, or petroleum 
ointment: the purified residue after 
distilling off the lighter and more 
volatile portions from American petro- 
leum. 



P* Unguenti zinci oxidi benzoinati, 

P* Hydrargyri oxidi flavi, gr. v. 

Unguenti petrolei purificati, gj. — 
M. 

B) Unguenti acidi carbolici, gj. 

fy Unguenti acidi carbolici, gss. 

Unguenti zinci oxidi benzoinati, 
giss.— M. 

P* Acidi salicylici, gr. xv. 
Petrolati, gj.— M. 

Epidermol. 

Besinol. 



Caustics. 



B> Acidi chromici, 

Aqua?, of each, 3j. — M. 

Chromic acid fused into a bead 
(page 129). 

Silver nitrate fused on a probe. 

Glacial acetic acid. 

Mtric acid. 

Monochloracetic acid. 

London paste. 

Trichloracetic acid. 

Electrocautery. 



Powders. 



Aristol. 

Nosophen. 

Iodoform. 

Boric acid. 

Morphia?, gr. 1 / 2 - 1 / 6 (for insuffla- 
tion). 

F* Bismuthi carbonatis, gr. ij. 



APPEXDIX REMEDIES. 



527 



IJ Sodii bicarbonatis, 
Sodii boratis, 
Amyli, of each, gr. iss. 
Cocainse hydrochloratis, gr. x. 
Sacehari lactis, q. s. ad gr. c- 



-M. 



IJ Morphise hydrochloratis. gr, ij. 

Bismuthi ?ubnitratis, 3vj. 

Pulveris acacise, 3ij. 
M. Signa: '"Terrier's snuff."' for 
cold in the head. 



Tablets. 



IJ Ammonii chloridi, gr. j. 

Tincturse opii canrphoratse, 

Syrupi scillse compositi, 

Syrupi Tolutani, of each, min. v. 

Extracti glycyrrhizse, gr. iij. 
M. Signa: Throat-, or cough-, tab- 
let. 

IJ Morphia? sulphatis, gr. V 12 . 
Atropise sulphatis, gr. 1 / 600 . 
CafTeinse, gr. V 6 . 
M. Signa : Coryza-tablet. 



R 



Local Anesthetics. 
Cocaine. 

Eucaine. 

xxcidi carbolici, 12 per cent. 
Glycerini, 88 per cent. — M. 



Gexeral Anesthetics. 
Ether. 

Chloroform. 

Ethvl-bromide : hvdrobromic ether 



Gexeeal Remedies. 

Sodium bromide in doses of 30 or 
60 grains in large amount of water, 
especially at bed-time. 



IJ Zinci valerianatis, gr. ij. 
Extracti nucis vomicae, gr, 
Extracti gentianae. gr. ij. 
M. Fiat pilula. 
Signa: One pill thrice daily 



l A. 



IJ Ammonii chloridi, 3j. 

Tincturse opii camphoratae, 

Syrupi scillae compositi, 

Syrupi Tolutani, 

Syrupi glyeyrrhizae, of each, §j. 
M. Signa: Teaspoonful every two 
or four hours. (Cough-syrup.) 

IJ Calcii sulphidi, gr. iij. 

Fiat in pilulas Xo. xij. 

Signa: One three times a day for 
suppuration. 

Acidi arseniosi, gr. 1 / 3 „ thrice daily 
for furunculosis oid herpes. 

IJ Tincturse ferri chloridi, 3ij. 
Glycerini, 5 j . 
Aquae, Siij- — M. 

IJ Ferri reducti, 

Quininae sulphatis, of each, gr. j. 
Strychnia? sulphatis, gr. 1 / 60 . 
M. Fiat in pilulam Xo. j. 
This pill may be taken two or three 
times a day, after meals. 



IJ Tincturse ferri chloridi. 
Glycerini, 

Aquae, of each, Sj- — M. 
(Billington's formula.) 



5j. 



IJ Hydrargyri chloridi mitis, . 

Sodii bicarbonatis, of each. gr. j. 
— M. 

IJ Hydrargyri chloridi corrosivi, gr. 

/lOO" /50- 

Sacehari albi. gr. iii-v. 

M. Triturate: fiat in chartulam 
Xo. j. 

Signa: Apply dry on the tongue 
every hour. (For diphtheria or 
croup.) 



Eemedies for Tixxitus Atjeitjm. 

IJ Acidi hydrobromici diluti, 3j- 
Aquae. Biij- 
M. Signa: A teaspoonful well di- 
luted three times a day. 



528 



APPENDIX REMEDIES. 



Fluid extract of cimicifuga race- 
mosa, in 30-drop doses daily. 



Febrifuges. 



Antipyrin. 

Phenacetin. 

Acetanilid. 



Sedatives. 
Exalgin. 

Potassium bromide. 

I£ Bromidise, §ij. 

Signa: One-half teaspoonful in 
water every half-hour until pain is 
relieved. 

Aconite. 

1$, Tincturse aconiti, 3ss. 

Potassii bromidi, 3iss. 

Aquse §ij. 
M. Signa: Teaspoonful every hour 
in tonsillitis. 



Emetics. 
Apomorphine. 

Hydrargyri subsulphas flavus (tur- 
peth mineral). 

Powdered alum. 

Ipecac. 

Sulphate of copper. 



Remedies for Rheumatic and 
Gouty Affections. 

Salicin. 
Salicylic acid. 
Salol. 



R^ Acidi salicylici, 3iij. 
Sodii bicarbonatis, 3ij. 
Elixiris gaultherise, §ss. 
Glycerini, 3iij. 
Aquse, q. s. ad Siv. — M. 

Lithium carbonate or citrate. 

Alkalithia. 

Citrate of lithia, soda, and potash 
(effervescent). 

Sodium phosphate (alkaline laxa- 
tive and cholagogue). 



Remedies for Tuberculosis. 
Codliver-oil and maltine. 



R< Vini ferri citratis, §iv. 

Signa: Dessertspoonful after each 
meal. 

R. Syrupi hypophosphitis compositi 
(Fellows's), Oj. 
Signa: A teaspoonful three times a 
day, after meals. 

IJ Olei morrhuae, Oj. 

Signa: A teaspoonful thrice daily, 
after meals, in lemon-juice or coffee; 
or inunctions twice daily, rubbing a 
tablespoonful into the skin of the ab- 
domen, and covering with oiled silk 
or flannel. 

Guaiacol in doses of 1 to 10 minims 
after each meal, given in glycerin, 
milk-broths, or wine. 

Creasote, 1 to 10 minims or more 
three times a day, given in milk, alco- 
holic or tonic preparations, or in cap- 
sules. 



Remedies for Syphilis. 

R Hydrargyri bichloridi, gr. j. 
Potassii iodidi, §ss. 
Syrupi sarsaparillae, 5iv. — M. 



APPENDIX EEMEDIES. 



529 



I£ Potassii iodidi, 3iv. 

Ammonii carbonatis, 3j. 

Elixiris simplicis, 3J- 

Infusionis calumbae, gv. 
M. Signa: Tablespoonful in water 
three times daily. (For syphilis and 
caries.) 

P* Syrupi ferri iodidi, 3iv. 

Glycerini, 3iss. 

Aquae, %iv. 
M. Signa: Teaspoonful three times 
a day. 

I£ Potassii iodidi, gr. viij. 

Ferri et ammonii citratis, gr. xxiv. 

Elixiris aurantli, Bij- 

Aquae, §ij. 
M. Signa: Drachm j or ij thrice 
daily. (For children.) 

Ifc Potassii iodidi, 3j. 

Ferri et ammonii citratis, 3ij. 

Infusionis calumbae, q. s. ad 5vj. 
M. Signa: Tablespoonful in water 
thrice dailv. 



Pilocarpine-hydrochlorate solution, 
2 per cent. Ten or 15 drops to be in- 
jected under the skin. (For labyr in- 
thai disease, syphilitic.) 



F* Sodii iodidi, §ss. 

Essentiae pepsinae (Fairchild), 
Syrupi zingiberis, of each, Biij ■ 
M. Signa: Drachm j ter die. 



Miscellaneous. 

Nitrite of amyl; used for inhala- 
tion in hay fever, asthma, and col- 
lapse from anaesthetics. Dose, 10 or 
20 drops. 



Pure camphor-menthol inhaled from 
a bottle or glass tube, for hay fever 
and cold in the head. 



530 



APPENDIX. 
CASE-RECORD BOOK. 



Date 






Name 






Nn. 


Residence 




Tel. No. 








Occupation 
















Business address 




Tel. No. 










Fees 


Referred by 




Age Sex 


Height 


Weight 
J Losing 
j Gaining 




Where born 




Single 

Married 

Widower 




How long in this climate 




Previous residence 




Chief complaint 




Other symptoms 


Ledger Page 


Onset 


Pruggist 


Supposed cause 


Tel. No. 


Family history — Heredity 







APPENDIX CASE-RECORD BOOK. 



531 



Personal History 



Diphtheria 

Scarlet fever 

Tonsillitis 

Grippe 

Measles 

Croup 

Hay fever 

Asthma 

Epistaxis 

Scrofula 

Lymphatic swelling's 



Paracusis 
Fluctuations 
Meningitis 
Otitis media 
Mastoiditis 



Phthisis 

Hemoptysis 

Night sweats 

Neuralgia 

Lues 

Paralysis 

Typhoid 

Erysipelas 

Eczema 

Lithemia 

Antrum trouble 



Autophonia 

Vertigo 

Cerumen 



Traumatic history 

Idiosyncracies 

Passed Life Ins. Exam.': 

Alcoholics 

Tobacco 

Former treatment 



Snu£! 



Narcotics 



532 



APPENDIX CASE-RECORD BOOK. 



Present Condition 



General 
health 



Deglutition 



Taste 



Appetite 

Empty swallowing 

Digestion 



Bowels 



Respiration 




Oral do. 


Sleep 




Snoring 


Mouth dry in morning 




Smell 


Coryza (recurrent) 






Which nostril 
most free 




Alternating 
stenosis 


Nasal 
secretions, Ant. 




Post. do. 


Frontal 


Temporal 


After exercise— reading 


Headache Occipital 


General 


Worse in morning 


Pain 




Memory 


Cough 




Expectoration 


Ozena 




Odor of breath 



Vocalist 



Vision 



Voice, (Hoarseness, aphonia, etc.) 



APPEXDIX CASE-RECORD BOOK. 



533 



Examination of Ear 



RIGHT 




LEFT 


DURATION 


Hearing impaired 


DURATION 


Tinnitus (kind) 


Discharge 


Pain 


1 1 
Causation 

2 2 


Course 


Auricle 


Ext. canal 



M. T. 
and 

Tympanum 



Eustach. tube 



Mastoid 



534 



APPENDIX CASE-RECOKD BOOK. 

Ear continued 



RIGHT 








LEFT 


1MPROV. 


PATENCY 


INFLATION 


PATENCY 


IMPROV. 






Valsalva 










Politzer 










Catheter 






OSSICLES 


M. T. 


Siegle 


M. T. 


OSSICLES 


AFTER INFL. 


BEFORE INFL 


FUNCTIONAL TEST 


BEFORE INFL 


AFTER INFL 






Speech 










Whisper 










Watch 










Aeoumeter 










Galton 










Subjective Sounds 










T.F. aerial 










Through Tube 








Weber 






Rinne 




BONE 


AIR 


Sehwabaeh 


AIR 


BONE 


2D TONE 


1 s t TONE 


Bing 


1st TONE 


2°TONE 


RELAXATION 


PRESSURE 


Gelle' 


PRESSURE 


RELAXATION 



Worse in bad weather 



Prognosis 



APPEXDIX CASE-RECORD BOOK. 



535 



Ear continued 



RIGHT 





o 

D 
Q 
Z 


o 


:r,i:£t untie 


_i 

LL 
Z 




o 

_i 


Lu 

I- 1 


Lu 


Date 






C-l 

64 


c 

128 


Ci 

256 


C2 

512 


C3 

1024 


C4 

2048 




A 


















B 












B 


















A 












A 


















B 












B 


















A 












A 


















B 












B 


















A 












A 


















B 












B 


















A 












A 


















B 












B 


















A 












A 


















B 












B 


















A 












A 


















B 












B 


















A 












A 


















B 












B 


















A 












A 


















B 












B 


















A 












A 


















B 












B 
















A 











536 



APPENDIX CASE-EECOED BOOK. 



Ear continued 





























LEFT 




o 

3 


ZRIZsTItTIE 


. 


iP=i 


o 

i— 
_i 


ul 


LtZ 


Date 


Q 

Z 






C-l 


c 


C1 


C2 


C3 


C4 


u. 

z 




H- 


1— 




u 
o 






64 


128 


256 


512 


1024 


2048 




< s 


C3 








A 


















B 












B 


















A 












A 


















B 












B 


















A 












A 


















B 












B 


















A 












A 


















B 












B 


















A 












A 


















B 












B 


















A 












A 


















B 












B 


















A 












A 


















B 












B 


















A 












A 


















B 












B 


















A 












A 


















B 












B 


















A 












A 


















B 












B 


















A 











APPENDIX CASE-RECORD BOOK. 



537 



RIGHT 



Examination of Nose 



Ant. naris and vestibule 



Ala nasi 


Septum 


// ,- 


Floor and inf. meatus 


Inf. turb. 


V 


Mid. meatus 


1/ 


Mid. turb. 


Sup. meatus and attic 




Ace. sinuses 


Polypi 



NASO-PHARYtU. 



Vomer 



Mid. turb. 



!nf. turb. 



Eustach. orifice 



Vault of pharynx 



538 



LEFT 



APPENDIX CASE-EECOED BOOK. 

Nose continued 



Ant. naris and vestibule 



Ala nasi 



Septum 



Floor and inf. meatus 



Inf. turb. 



Mid. meatus 



\ f 



Mid. turb. 



Sup. meatus and attic 



Ace. sinuses 



Polypi 



NASO-PHARYNX. 



Vomer 



Mid. turb. 



Inf. turb. 



Eustach. orifice 



Aprosexia Pharyngeal tonsil 



APPEXDIX CASE-RECORD BOOK. 539 

Examination of Mouth and Fauces 

Teeth 



Gums 



Hard palate 



Velum 



Uvula 



Pharynx 



Lateral folds 



Tongue 



Lingual tonsil— Varices 



RIGHT LEFT 

Tonsil 



Ant. pillar 



Post, pillar 



Thyroid 



Cerv. glands 



5^0 



APPENDIX CASE-KECOED BOOK. 



RIGHT 


Examination of Larynx 


LEFT 


Epiglottis 


Ary-epiglottic foids 


Arytenoids 


Inter-aryt. space 


Ventricular bands 


Vocal cords 


Abduction 


Adduction 


Trachea 


Esophagus 


Lungs 







INDEX, 



Abbott, 355, 359 
Abbreviations, 4 
Abel, 269 

Abscess, cerebral and cerebellar. 121, 
145 

extradural, 144 

metastatic, 145 

of brain, 121, 145 

of larynx, 481, 482 

of neck, 141, 181 

of nose, 292 

retropharyngeal, 152, 182, 433, Plate 
V 

subdural, 144 

tonsillar, 399 
Accessory cavities of the nose, dis- 
eases of, 297 
Acoumeter, 27 
Acute otitis externa, 58 
Acute otitis media, 73 

appearances of membrana tympani, 
20, 21, Plate I 

grip as a cause, 73 

leech, artificial, 76 

leeches, 76 

naso-pharynx, 73 

paracentesis membranae tympani, 77 

relief of pain, 75 

treatment, 75 
Acute purulent otitis media, 78 

grip as a cause, 73 

influenza as a cause, 73 

membrana tympani, appearance of, 
78, 81, Plate I 

micro-organisms, 78 

treatment, 79 
Adenoid hypertrophy of vault of 
pharynx, 324 

ear complications, 195, 324 
Adenomata of pharynx, 324 
Adjustable light, 13-17 
Age, influence of, in diseases, 5 
Agnew, 184 

Air, compressed, and apparatus, 29-41 
Air-pressure, 29 
Alderton, H. A., 199 
Alkaline sprays, Appendix 
Alt, 313 
Amaurosis, 312 
Amblyopia from nasal disease, 312 



Anaesthesia, local, in nasal surgery. 
265 

of pharynx, 436 
Anaesthetics, general, 146, 157, 327 
Andrews, A. H., 212 
Angina, catarrhalis acuta, 335 

Ludwig's, 405 

rheumatic, 342, 344 
Ankylosis of the ossicles, 90, 95, 98 
Anomalies, of auricle, 52, 55 

of external meatus auditorius, 54. 
55 

of sensation in larynx, 487 
Anosmia, 286 

Antiseptic sprays, Appendix 
Antrum, aditus'ad, Figs. 108, 109. 110 

mastoid, Figs. 109, 110 

of Highmore, 297 
Aphonia, 476, 489, 490 
applicator, caustic, 129 
Aquaeductus Fallopii, 166, 167. Figs. 

109, 110 
Arnold, J. D., 456 
Arrangement of instruments, 13, 14 
Arslan, 196 

Artificial drum-heads, 132 
Aspergillus of the ear, 62 
Aspirator for the ear, 125 
Asthenopia from nasal disease, 310 
Asthma, 229 

from nasal disease, 231, 259, 277, 291 
Astigmatism from nasal disease, 312 
Asymmetry of nasal bones, 255 
Atmospheric causes of disease, 8-11, 

317 
Atomizers, 210 

Atresia, of external auditor v meatus. 
54, 64 

nasal, 294 
Atrophic rhinitis, 268 
Audiphone, 200 
Auditory canal, 56 

acute inflammation, 58 

boils of, 60 

bony growths, 64 

cerumen. 56 

chronic inflammation, 58 

exostoses, 64 

foreign bodies. 65 

furuncles, 60 

» (541) 



5+2 



INDEX. 



hyperostosis, 64 

imperforate, 64 

malignant disease, 48, 50 

narrowing, 64 

neoplastic closure, 64 

parasitic inflammation, 62 

sequestra, 139 
Auditory nerve, 187-191 
Aural, fungi, 62 

vertigo, 57, 183, 185, 186, 193 
Auricle, benign tumors of, 51 

carcinoma, 50 

cutaneous diseases, 47 

cystoma, 51 

deformities, 52-55 

eczema. 47 

frost-bite, 47 

gangrene, 49 

hematoma, 51 

herpes, 52 

hypertrophy, 52 

inflammatory affections, 47-52 

intertrigo, 52 

lupus, 48 

malignant disease, 50 

othematoma, 51 

pemphigus, 52 

perichondritis, 50 

scroll-deformity, 54 

syphilis, 52 

wounds and injuries, 55 
Auscultation-tube and method of 

using, 45, 46 
Autoaspiration, 88 
Autoinnation of the middle ear, 101 
Automatic tuning-fork, 23 
Autophony, 74, 86 
Autoscopy, 447 



Babcock, R. H., 382 

Bacon, G., 67 

Bag, ice-, 153 

Baginsky, 358 

Baldness not a cause of disease, 10 

Bandage, net, 180 

Barclay, Robert. 114 

Barr, Thomas, 62 

Baum, W. L., 395 

Baurowicz, 269 

Bean. C. E., 403 

Becker. B., 384 

Behrens, B. M., 109 

Behring, 375, 377 

Bell, A. G., 201 

Bergmann, 145 

Bertillon, 238 

Bezold. 78, 133, 134 

Bifid uvula, 418 

Billings, Frank, 397 



Bing's hearing-test, 25 

Bischoff, 490 

Bishop, D. D., 395 

Bishop, S. S., 314 

Black, G. M., 268 

Blake, Clarence J., 114, 115 

Bleeding, local, in acute otitis media, 

76 
Blepharitis, 309 
Blindness from sphenoid disease, 303, 

312 
Boils in the external ear, 60 
Bone, turbinated, inferior, Plates II, V 
middle, Plates II, V 
superior, Plates II, V. 
Bone-conduction, 22, 24 

in chronic aural catarrh, 94 
Bostoek. John, 230 
Bosworth, Francke H., 253 
Bouchut, 464 
Bougies, Eustachian, 72 

nasal, 228 
Boxing the ears, 51, 67 
Bracket, adjustable lamp-, 17 
Brain-abscess, 121, 145 
Brannon, John Winters, 383 
Braun, 270 

Brennecke, H. A., 395 
Bresgen. 309, 311 
Broadbent, 239 
Brown, Dillon, 463 
Brown, Moreau R., 253 
Browne, J. Lennox, 369, 370, 385, 421, 

511 
Brown-Sequard, on hematoma, 51 
Bryant, W. S., 121 
Buck, A. H., 66 
Burnett, Charles H., 62, 114 
Burns and scalds of the pharynx, 437 



Caisson, effect on ear, 33 
Calcareous degeneration of the middle 
ear, 90, 91, 131, Plate I 
Camphor-menthol, 215 

inhaler, 217 
Canal, external auditory, 56, 113 

Fallopian, 166, 167, Figs. 109, 110 

glands, 113 

imperforate, 64 

section of, 113 
Canalis tensoris tympani, 70 
Cancer of pharynx, 430 
Carcinoma, of ear, 50 

nose, 279 

larynx, 508 

pharynx, 430 
Caries and necrosis from middle-ear 
diseases, 117, 120, 129, 
130, 134, 138 



INDEX. 



543 



Carotid artery, rupture of, in suppura- 
tion of middle ear, 139 
canal, 169, 170 
Cary, Frank, 469 
Case-records, 22, 28 
Casselberry, William E., 252 
Catarrh, chronic, of middle ear, 83, 90 
exudative, 83 

hypertrophic, of the nose, 255 
of the middle ear, sero-mucous, 83 
Catarrh, heredity of, 318 
Catarrh, nervous, 229 
Catarrhal otitis media, acute, 73 
Catheter, Eustachian, 43 
in chronic aural catarrh, 88 
method of using, 42, 44, 45 
Causes of disease, atmospheric, 8-11, 

317 
Caustic, applicator, 129 
chemical, 128 
for nose and throat, 260 
Cautery, electric, 259-267 
Cavities, accessory, of nose, 297 
Cerebellar abscess, 145 
Cerebral abscess, 145 
Cerumen, impacted and inspissated, 

56 
Chapman, J., 253 
Charcot, 191 

Cheatham, William, 253, 314 
Chiari, 270, 510, 512 
Cholesteatoma, of mastoid, 133 
of middle ear, 133 
Stacke's operation, 172 
Chondromata, nasal, 276 
Chorda tympani nerve, 106 
Chorditis tuberosa, 482 
Chorea, of pharynx, 436 
Chronic catarrh of the middle ear, 83 
adhesive inflammation, 90 
age, 92 

alcohol, effects of. 86, 92 
ankylosis of ossicles, 90, 95, 98 
atrophic stage, 85, 90, 95 
auditory hallucinations, 189 
autoaspiration in, 88 
autophony, 74, 86 
calcareous degeneration, 90 
climatic conditions, 86, 89, 93, 317 
deafness, 90, 93-95 
differential diagnosis, 86, 95 
electricity, 103 
Eustachian, catheter, 88, 100 

tube, 69, 85 
excision of membrana tympani 

and ossicula, 108, 110 
exudation, 83 

foreshortening of handle of mal- 
let. 84. 96, Plate I 
frequency of, 7, 8 



Chronic catarrh of the middle ear, 

heredity, 92 
hygienic surroundings, 8-10 
hypersemia, 83 
hypertrophic, 83 
injection of liquids, 99, 100 
injection of vapors, 100 
loud noises, effects of, 93 
ossicles in, 90 
otalgia, 85 
pain in ear, 85, 93 
paracentesis, 88 
paracusis, 95 
partial excision of membrana 

tympani, 107 
peculiar modifications of hearing, 

94, 95 
pneumatic tests, 85, 95 
proliferation, 90 
removal, of membrana tvmpani 

and ossicles, 108, 110 
stapes, 115 
retraction of membrana tympani, 

84 
sclerosis, 90 
secretive, 83 
sensations of discomfort, 85, 86, 

92, 93 
statistics, 4-12 

tenotomy of tensor tympani, 108 
tinnitus aurium, 92, 97, 188 
tobacco, effects, 92, 189 
uric acid, 91 
vertigo, 93, 97 
purulent otitis media, 116 
antiseptic, powders, 122-124 

solutions, 121, 124, Appendix 
appearances of membrana tym- 
pani, 116, Plate I 
caries and necrosis, of adjacent 

tissues, 120, 129, 138, 139, 

140, 141, 142 
of ossicles, 117, 130 
caries of carotid canal, 139 
cause of intracranial lesions, 121, 

139, 152 
cerebral abscess from, 121, 139, 

152 
cholesteatoma. 118, 133 
excision of drum-head and os- 
sicles, 108, 130 
exfoliation of cochlea, 138 
facial paresis and paralysis, 121, 

134 
granulations, 120, 127 
mastoid complications, 119, 152 
meningitis, 121, 143 
metastasis, 145 
paralysis and paresis, facial, 121, 

134 



5U 



INDEX. 



Chronic purulent otitis media, per- 
foration of the membrana 
fiaccida, 117 
phlebitis of lateral sinus and jug- 
ular vein, 140, 147 
polypi, 120, 127 
pyaemia, 121, 140 
rupture of carotid artery, 139 
seat of intracranial lesions, 121, 

140, 152 
sequelae, 121, 127, 152 
symptoms, 119 

of brain-abscess, 145 
of sinus-thrombosis, 147 
thrombosis of lateral sinus and 

jugular veins, 147, 148 
treatment, 121 
Chronic suppurative tympanitis, 116 
Chronicity of diseases, 9 
Circumscribed otitis externa, 60 
Cirrhotic rhinitis, 268 
Clark, Sir Andrew, 254 
Classification, of diseases, 4-12 
of occupation, sex, etc., 3-11 
Climatic influences, 18, 317, 335, 423, 

457 
Clinical records, 3, 28, Appendix 
Clothing, 225, 321, 346, 463 
Cocaine, 228 
Cochlea, 141 

exfoliation, 138 
Cohen, J. Solis-, 253, 351, 422, 423 
Cold, catching, 317, 335 
Cold in the head, 223 
Coleman, W. F., 310 
Colles, C. G., 92 
Comparison of statistics, 11 
Compressed air, 29-41 
apparatus, 36-41 
meter, 30, 37 
Congenital deafness, 195 
Conjunctivitis from nasal disease, 308, 

310 
Conklin, 237 
Coppez, 312 
Corbin, 463 

Corneal inflammation from nasal dis- 
ease, 310, 311 
Coryza, 223, 226 

tablets, 222, 225 
Cotton, A. C, 395 
Cotton-carrier, 19 
Cough-tablets, 339 
Cozzolino, 115 
Croup, 458 

intubation, 464 
laryngismus stridulus, 461 
membranous, idiopathic, 458 
spasm of the glottis, 459 
spasmodic, 486 



Croup, spurious, 452 

tracheotomy, 470 

choice of operation, 471 

treatment, 461 
Curettes, 141, 158 
Curtis, H. H., 253 
Cut-off, compressed air, 31 
Cutter, Ephraim, 507 
Cystoma, of auricle, 51 

larynx, 505 

Dabney, Samuel G., 311 
Dacryocystitis from nasal disease, 310 
Dalby, W. B., 65 
Daly, W. H., 253, 300 
Darwin, 242 
Davey, James R., 139 
Davis, Nathan Smith, 237, 250 
D'Espine, 358 
De Lamalleree, 254 
De Vilbiss, Allen, 146, 443 
Deaf-mutism, 195, 324 
Deafness, causes of, 71, 74, 86, 94, 119, 
184, 185, 186, 191, 194, 
319 

congenital, 195 

following suppuration of middle ear, 
1L2 

hereditary, 196 

hysterical, 191 
Deflections of septum nasi, 287 
Eeformities, of auricle, 52 

of nasal cavities, 287, 294 
Delavan, D. B, 293, 330, 414 
Delstanche, Charles, 88, 99, 122 
Dench, Edward B., 136 
Desire, 497 
Dilators, for ear treatment, 36 

for nose, 228 
Dionisio, 270 
Diphtheria, 355 

age of patients, 358 

bacillus, 356 

diagnosis, 363 

diphtheric exudate, 355 

diphtheroid, 363 

effect, on ear, 362 
eye, 311, 312, 362 

incubative period, 359 

intubation. 464 

microbe, 355 

modes of propagation, 360 

of the nose and naso-pharynx, 362 

prophylaxis, 366, 376, 380 

pseudodiphtheria, 331, 363 

symptoms, 360 

treatment, 365 
antitoxin, 375 
hygienic, 366 
internal, 373 



INDEX. 



545 



Diphtheria, treatment, local, 369 

serum-therapy, 375 

tracheotomy, 442 

vitality of Klebs-Loffler bacillus, 
358, 3ou 
Diphtheroid, 363 
Direct laryngoscopy, 447 
Disinfection, lOki 
DobelFs solution, Appendix 
Double hearing, 188 
Double retractors, 160 
Double uvula, 418 
Douche, nasal, 212, 271 
Douglas, O. B., 287 

Drumhead. See Membrana tympani. 
Ducts emptying into nasal meatuses, 

'Figs. 179, 181, 182 
Duel, A. B., 73 
Dunn, J., 310 
Dynamomotor, 262 
Dysphonia, 505 

Ear, electrodes, 137 

internal, 183 

malformations, 52, 54 

middle, 67, 69, 113, Figs. 109, 110 

noises, subjective, 56, 74, 85, 92, 
188 

relation of nose to, 69 

specula, 17 
Ear-cough, 57 
Ear disease, brain-abscess, 145 

from disorders of nervous system, 
187, 191, 192 

from exanthemata, 73 

from grippe, 73 

from influenza, 73 

from intracranial growths, 193 

from leucocythsemia, 186 

from meningitis, 192 

from syphilis, 186 
Ear- fungi, or mold, 62 
Ebstein, "236 

Ecchondrosis, nasal cavities, 276 
Eczema of auricle, 47 

evelid and face, 310 
Ehrlich, 375 

Electric current-transformer, 262, 263 
Electric motor, 2.J2 
Electricity in various diseases, 103, 

137, 259-267 
Electrodes, ear-, 137 
Emphysema from Eustachian catheter, 

46 
Empyema, of antrum of Highmore, 
297 

of frontal sinuses, 303 

of maxillary sinuses, 297 
Fno-ehnann. Rosa, 382 
Enslee, Charles L,, 3 



Epiphora from nasal disease, 310, 312 
Epistaxis, 272 

plugging nares, 273 
Epithelioma, of ear, 50 
of larynx, 508 
of nose, 279 
of pharynx, 430 
Erectile tumors of nasal cavities, 276 
Ethmoid sinuses, diseases of, 301 
osteoma, 303 
polypi, 303 
Etiology of diseases, 9-10 
Eustachian, catheter, 43 

emphysema from use of, 46 
method of using, 42 
salpingitis, 69 
tube, 69, 256, Plate II 

canal is tensoris tympani, 70 
cartilage of, 70 
constriction of, 72 
fossa of Rosenmiiller, 44 
isthmus, 70 
membranous part, 70 
orifice, 44, 70 
patency, 72 
stenosis, 72 
Euthanasia, 511 
Ewing, 387 

Examination of patients, 13, 205, 443 
Exanthemata, effect on ear, 9 
Excision, of membrana tympani and 
ossicula, 108, 110 
partial, of membrana tympani, 107 
Exostoses, of auditory canal, 64 

of nasal cavities, 277 
External ear, 47 

auricle, 47 
Extradural abscess, 144 
Exudative catarrh of middle ear, 83 
Eye diseases from diseases of the nose, 

307 
Eye-strain, 315 

Facial expression in diseases of the 

nose and throat, 325 
Facial paralysis, 121, 134. 177 
Faith, Thomas, 46 
Fallopian canal, 166, 167, Figs. 109, 

110 
False diphtheria, 357 
False hearing, 188 
Farcy, 284 
Fatality of chronic suppuration of the 

middle ear, 116, 139, 143, 

145, 152 
Fenestra, ovalis, Fig. 107 

rotunda. 118 
Fessler, 327 

Fibroids, of larynx, 502 
of nasal cavities, 274, 322 



5-46 



INDEX. 



Fick, 335 

Fischer, 311 

Floor of the tympanum, 113 

Folds of membrana tympani, 21 

Foreign bodies in ear, 65 

in larynx, 513 

in nose, 294 

in pharynx, 438 
Fork, automatic tuning'-, 23 
Fossa of Rosenmliller, 44, Plate II 
Foster, 381 
Fournier, 427 
Fracture, of base of skull, 194 

of nose. 293 
Frankel, 503 
Frankenberg, 195, 324 
French, J. M., 293, 395 
Frequency of disease, relative, 3, 7, 8 
Frontal sinuses, diseases of, 303 

transillumination, 305 
Frost-bite of auricle, 47 
Fruitnight, 462 
Fungi, aural, 62 
Funk, 312 
Furuncles, of ear, 60 

of nose, 285 

Galezowski, 314 

Galton's whistle, 26 

Galvanocautery, 260 

Ganglion, sphenopalatine, 231 

Gangrene of the ear, 49 

Garcia, 451 

Gelle, 115 

Gelle's hearing-test, 26 

General considerations, 3 

Glanders, 284 

Glasgow, W. C, 252, 423, 462 

Glaucoma, 311 

Gleason, on sclerosis, 114 

Gleitsmann, J. W., 287 

Glenoid fossa, 168 

Globus hystericus, 436, 439, 488 

Glottis, spasm of, 454 

Gluck, I., 254 

Goldstein, M. A., 138, 198, 295 

Gonorrhoea, nasal, eye symptoms, 311 

Gottstein, 462 

Gouges, 157 

Gouguenheim, 254, 403 

Gould, G. M., 309 

Gout, a cause of hay fever, 242, 248 

effect on the ear, 91 
Gouty sore throat, 342, 344 
Gradle, Henry, 129, 253, 314, 380 
Grant, J. Dundas, 100, 462, 506 
Granulations, in suppuration of the 
middle ear, 120, 127 

of vocal cords, 482 
Gray, L. C, 240 



Greene, J. O., 108 
Grippe, 219 

cause of otitis media, 73, 222 

effect on ear, 94, 222 
Gruber, Josef, 29, 184 
Gruhn, 310 
Guenod, 311 
Gummata, of larynx, 498 

of pharynx, 424 
Gunn, Moses, 299 
Guttmann, 311, 373 
Guye, 191 

Hack, 310 

Hsematoma, of auricle, 51 

of nose, 292 
Haemorrhage, from adenoid operation, 
330 

of internal ear, 185, 194 

nasal, 272 
Hagenbach, 386 
Haig, Alexander, 236, 237, 238, 239, 

240 
Hajek, 269, 510 
Hall, Marshall, 486 
Hallucinations, auditory, 189 
Hamilton, T. K., 31u 
Hanau, 405 
Hansell, 312 

Hardie, T. Melville, 253, 331 
Hare, 382 
Hartmann's inflation experiments, 33 

tuning-forks, 23, 24 
Hasse, 431 
Hay fever, 229 

etiology, 242 

gout, 248 

medical opinions, 251 

nasal disease in, 231 

neurosis, 229 

pathology, 229 

symptomatology, 244 

treatment, 246 

uric acid, 236 
Head-mirror, 16 
Hearing, double and false, 188 

instruments, 199 

tests of, 21-27 
Henoch, 358 

Hereditary deafness, 92, 196 
Herpes of auricle, 52 
rieryng, 305, 422, 482, 504 
Highmore, antrum of, 297 
Hollister, J. H., 395 
Holmes, C. R., 165-172 
Hooks, double mastoid, 160 
Hooper, 330 
Horslev, 146 
Hotz, F. C, 73 
Hubbard, Thomas, 431 



INDEX. 



5L7 



Hutchinson. 186 
Hydrorrhea, 227.. 24^. 315 
Hyperesthesia acoustica, 187 
Hyperesthesia, of larynx. 487 

of nose. 232. 244 

of pharynx. 435 
Hyperaudition. 187 
Hyperostosis in auditory canal, 64 
Hyperplasia, nasal cavities. 244 
Hypertrophies, nasal cavities. 255, 324 

posterior, surgery of. 324 
Hypertrophy, of auricle, 52 

of tonsils, 405 
Hysterical, deafness. 191 

aphonia. 489, 492 

Ice-bag. 153 

Illumination, 13-17, 156 
Imperforate external meatus, 64 
Incision of membrana tympani, 105, 
155 

over mastoid process. 155 
Incus. 106. 113. 139. 141 

articulation, 106, 113. 141 
Inflation of tympana. 41-44 

Politzers method, 41 

Valsalva's method. 34 
Inflators. 42. 43 
Influence, of age on diseases, 3, 5, 7 

of occupation. 3. 5. 7 

of sex. 3. 5. 7, 11 
Influenza. 219 

cause of otitis media. 73. 222 

effect on ear. 94. 222 
Ingals. E. Fletcher, 253. 353. 422 
Inhalents. 215 
Inhalers, 217, 249 
Instruments, ear, 111, 128 

hearing-, 199 

mastoid. 157-163 
Insufflators, 60, 122. 429 
Insurance, life-. 515 
Internal ear. 183, 194 

anaemia, 183 

aural vertio-o. 93. 144. 145. 148. 183. 
185. 186, 192, 312 

concussion of labyrinth. 194 

fracture at base of skull. 194 

haemorrhage, 185 

hyperemia, 183 

hyperesthesia acoustica. 187 

hysterical deafness. 191 

leucocythemic deafness, 186 

Meniere's disease, 185 

new growths, 193 

panotitis, 184 

primary acute labyrinthitis. 183 

suppurative exfoliation, 138 

syphilis, 186 
Intertrigo of auricle. 52 



Intubation of larynx. 464 
Iritis from nasal disease, 311 

Jack, Frederick L., 114 
Jackson, 186 
Jackson. A. Reeves, 240 
Jar vis, 506 
Jewell. J. S.. 247 
Joal. 241 
Jones, 126 
Jones. Bence, 247 
Jugular, fossa, 113, 169 
vein, phlebitis of, 147, 148 
thrombosis of, 147, 148 

Karlinski, 381 

Kassowitz. 386 

Keratitis from nasal disease, 310, 311 

Kinnear. B. O.. 253 

Kirstein. A.. 448 

Kitasato. 375. 379 

Kitchen, 253, 403 

Klebs. Edwin Theodore, 355, 388, 389 

Knapp. H.. 147, 192 

Knife in septum deformities. 268 

Knight. C. H.. 252, 330 

Knight. F. I.. 482 

Koch, 378 

Koerte, 384 

Korner, 146 

Kossel. 378 

Kramer. 196 

Krause, 422. 512 

Krieger, George E., 377 

Kriickmann. 405 

Kuh. Edwin J., 253 

Krister. 147 

Labyrinth, concussion, 194 

injuries. 194 
Labyrinthitis, nrimary acute. 183 
Lacrymal canal, affection of, from 

nasal disease, 308. 310* 
Lacrvmation from nasal disease. 308 
Laker. 270 
Lange. 250 
Langerhans, 38S. 390 
Laryngeal, paralysis, 489. 491 

spasm. 454. 486 
Laryngismus stridulus. 4Hi> 
Laryngitis, acute. 452 
symptoms, 452 
treatment. 455 

atrophic. 480 

catarrhal. 452 

chronic, 474 
treatment. 47S 

cedematous. 4S2 

phlegmonous. 481, 482 

purulent. 481 



548 



IXDEX. 



Laryngitis, rheumatic, 456 
simple, 452 
spasmodic, 454 
stridulous, 454, 461 
suppurative, 481 
syphilitic, 498, 
Laryngoscopic image, Plate V 
Laryngoscopy, difficulties of, 446 
direct, 447 
indirect. 443 
Larynx, abscess of, 481, 482 
acute catarrh of, 452 
anomalies of sensation, 487 
chronic catarrh of, 474 
examination, 443, 447 
foreign bodies in, 513 
treatment, 513 
laryngotomy, 507 
tracheotomy, 470 
growths in, 502, 507 
carcinomata, 508 
cystomata, 505 
epitheliomata, 508 
fibromata, 502 
mucous polypi, 50i 
myxomata, 504 
pachydermia, 503 
papiilomata, 502 
polypi, 504 
sarcomata, 512 
intubation of, 464 
neuroses of, 486 

aphonia, 476, 489, 490 
hyperesthesia, 487 
neuralgia, 487 
paralysis, 489, 491 
spasm of glottis, 454, 486 
oedema of, 482 

stenosis, 484, 498, 500, 501, 509 
syphilis, 498 
tuberculosis, 494 
tumors, 502, 507 
vocal bands, Plate V 
Lateral sinus, 140, 150, 166, 169 
phlebitis of, 147 
thrombosis of, 147 
Laurens, 312. 313 
Lavolin, 72, 215 
Lederman, M. D., 149, 155 
Leeches, 76, 154 
Lees, D. B., 254 
Lefferts, 513 
Leflaive, 237 
Letter, 403 
Leland, G. A., 85 
Leonard, C. H., 490 
Leucaemia, effect on ear, 186 
Lever, 236 
Levy, Robert. 423 
Life-insurance, 515 



Light for examination, 13-17, 156 

Light-condenser, 15 

Lincoln, P. P., 349 

Linea temporalis, 168 

Loewenberg, 269 

Loftier, 355, 371, 372 

Love, I. N., 373 

Lucse, 99, 133 

Ludwig's angina, 405 

Lupus, of the ear, 48 

of the nasal cavities, 283 
Luschka, tonsil of, 319, 324 
Lyman, H. M., 395 

MacCoy, Alexander W., 434 

Mace wen, i46 

Mackenzie, John Noland, 253 

Mackenzie, Sir Morell, 406, 490, 511 

Ivxaggots in the nose, 295 

Malformations of the ear, 52, 54, 55 

Malignant disease from suppuration of 

the middle ear, 48 
Malignant neoplasms, in nasal cavi- 
ties, 279 
Malleus, 68, 106, 113, 139, i41 
fracture of, 104 
ligaments, 68 
Marckwort, 315 
Marcy, 238 
iviartin, 375 

Massage, otoscope, 18, 98 
of external meatus, 102 
treatment, 18, 98 
Mastoid, antrum, Figs. 109, 110 
cells, Figs. 109, 110 
curettes, 158 

disease in otitis media, 78, 149 
guide, 158 
hooks, 160 
inflammation, 149 
cholesteatoma, 133 
complications of, 143, 149, 181 
instruments for operation, 155-163 
operative treatment, 155, 162 
primary, 149 
sclerosis, 151 
operations, 155, 162-181 

haemorrhage in, 162, 166 
portion, temporal bone, Figs. 109- 
110 
Maxillary sinus, 297 
Mavs, Thomas J., 237 
McBride, P., 126, 254 
Meatus, external auditory, 56. 113 

internal auditory, 150, 165, 174 
Membrana flaccida, perforations of. 

117, Plate I 
Membrana tympani, 20, 21, Plate I 
atrophy of, 84, 95 
chorda tympani, 106 



IXDEX. 



549 



Membrana tympani, excision of, 108, 
110 

folds, 21, 106 

granulations, 120, 127 

haemorrhage, 07 

hyperaemia, 08 

inflammation, 08 

adhesions, 91, 97, 130, 132 

injuries. 07 

inspection, 20 

massage of, 18 

membrana, flaccida, 21 
propria. 21 

normal, 20, 21 

paracentesis of, 77. 88. 105 

perforation, 73, 77. 110. 118, 131 

pockets, or pouches. 08 

polypi, 120, 127 

position of ruptures. 117 

Prussalcs fibres. 21 
space, 08 

resection of. 107, 108. 110 

retraction of. 71. 84. 95. 97. Plate I 

rupture of. 33, 07, 73. 194 

shape, 20. 21 

ShrapnelPs membrane. 21, 68 

thickening of. 85, 95 

topographical relations. 113 

topography, of outer surface, 21 
of inner surface, 106 

umbo, Plate I 
Membranous sore throat. 352 
Meningitis, 143 

effect on ear, 192, 195 
Metastasis in suppuration of the mid- 
dle ear. 145 
Meter, air-, 30. 37-40 
Michael's inflation experiments. 35 
Middle ear. 73. 113. 141. Figs. 109, 110 

chronic catarrh of, S3. 90 

gouty and rheumatic diathesis, 91 

instruments, 111, 128 
Migraine, 230 
Milbury, F. S.. 144 
Miles. 315 
Mirror, forehead-. 16 

-holder. 16 

throat. 207 
Mittendorf, W. F.. 308 
Mobilization of the ossicles. 104. 114 
Moisard. 378 
Monod. 378 
Moos. 149. 184, 192 
Mouth-breathing, 319. 325. 406 
Mulhall, 475 
Murchison, 236 
Murdoch. E. P., 393 
Mutes, deaf-. 195 
Mycomyringitis, 62 



Mycosis, of ear. 62 
of pharynx, 414 

Mvgind, 196 ' 

Myles, R. C„ 403 

Myringitis, 68 
parasitica, 62 

Myxomata, of larynx, 
nasal, 274 



504 



Xarcosis, bromide-of-ethyl. 327 
Nares, posterior, plugging in epistaxis. 

273 
Xasal adenomata, 324 
atresia, 294 
carcinomata, 279 
cavities, abscess of septum nasi. 292 

adenoma. 324 

anosmia, 286 

blood-tumors, 292 

bony occlusion, 277 

chondromata, 276 

cold in head. 223 

cystic polypi, 275 

deformities. 287, 294 

deviation of the septum. 28/ 

ecchondrosis. 270 

erectile tumors, 276 

exostosis, 277 

eve diseases from nasal affections. 
307 

fibrous polypi, 274 

foreign bodies. 294 

furuncles, 285 

glanders, 284 

hyperplasias, 255 

hypertrophies. 255 

lupus. 283 

maggots. 295 

malignant neoplasms, 278 

mucous polypi. 274 

osteomata. 277 

papillomata, 276 

parosmia, 286 

perforations of septum. 227. 292 

polypi, 274 

rhinoliths, 27S 

sarcomata. 278 

sen^e of smell. 286 

supporter for nose. 283 

synechia?, 255 

syphilis, 280 

tuberculosis, 280 
disease in hay fever, 231, 233 
diseases from eye affections, 315 
douche, 212, 271 

cause of inflammation of the mid- 
dle ear. 73 
duct. 308 
haemorrhage, 272 
myxoma, 274 



550 



INDEX. 



Nasal polypi, 274 

reflex neuroses, 231, 312 
septum, 255, 287, 297 
speculum, 206 
stenosis, 255 
Naso-pharyngeal diphtheria, 362 
Naso-pharynx, 317 

climate, effect of, 317 
Eustachian tube, 70,' 256, Plate II 
fossa of Rosenmuller, 44, Plate II 
tonsil of Luschka, 319, Plate II 
diseases of, in otitis media, 69 
atrophic catarrh, 321 
diphtheria, 362 
examination, 205 
facial expression, 325 
follicular catarrh, 317 
polypi, fibromucous, 323 

fibrous, 322 
tumors, 322 
voice, 326 
Neck-abscess, 181 
Necrosis of adjacent structures in 

middle-ear disease, 138 
Neisvr anger, C. S., 262 
Neoplasms, of larynx, 502, 507 
of nose, benign, 274 
malignant, 278, 279, 507 
Nerve, auditory, 187 

facial, 134, 166, 167, 170, 177, 191 
olfactory, 286, 293 
Nervous catarrh, 229 
Net bandage, 180 
Neuralgia, of larynx, 487 

of pharynx, 435 
Neuroses, nasal reflex, 231, 312 
of ear, 187 
of larynx, 486 

of nose, asthmatic, 244, 245, 259, 291 
eye disease, 312 
hyperesthesia, 232, 244 
migraine, 236 
reflexes in the eye, 312 
respiratory, 231, 244 
treatment', 246, 315 
of olfaction, 286 
anosmia, 286 
parosmia, 286 
of pharynx, 435 
Neurotic character of hay fever, 229 
Nevius, the, light, 156 
Newcomb, J. E., 330 
Newman, 512 
Nieden, 311 

Noises in the ear, 74, 86, 92, 133, 188 
North, John, 254, 271, 353, 369 
Northrup, 458, 468 
Nose, 205 

diseases of, abscess of septum, 292 
accessory sinuses, 297 



Xose, diseases of, affecting the eye, 307 

animate foreign bodies in, 295 

anosmia, 286 

asthma, 244, 245, 259, 291 

carcinoma, 279 

deformities, 287, 294 

diphtheria, 362 

epistaxis, 272 

examination, 205 

foreign bodies, 294 

furunculosis, 285 

glanders, 284 

hematoma, 292 

lupus, 283 

maggots, 295 

nose-bleeding, 272 

ocular symptoms, 307 

ozena, 268 

parosmia. 286 

polypi, 274 

rhinitis, acute, 223 

chronic, hypertrophic, 255 
simple, 226 

rhinoliths, 278 

sarcomata, 278 

septal perforations, 292 

sprays, 215 

supporter for bridge and tip, 283 

syphilis, 280 

tuberculosis, 280 
ducts, 308, 309 

examination and instruments, 205 
fractures, 293 
hematoma, 292 
pathological conditions affecting the 

eye, 307 
relation to the ear, 69 
Nose-bleeding, 272 
Noyes, H. B. f 314 
Nuttall, 382 



Occlusion of nasal cavities, 255, 294 
Occupations, influence of, 3, 5 , 

classified, 3 
O'Dwyer, Joseph, 461, 464 
(Edema, of eyelids from nasal disease, 
312 
glottidis, 482 
of larynx, 482 
Ohmann-Dumesnil, A. H., 420 
Olfaction, neuroses of, 286 
Olfactory nerve, 286 
Ophthalmia, gonorrheal, from nose, 

311 
Optic nerve, compression of, from 
sphenoid disease, 303, 312 
Orbital cellulitis, 311 
Ossicles, auditory, 106, 113, 139, 141, 
Figs. 109, 110 



IXDEX. 



551 



Ossicles, articulation. 106, 113 
caries of, 117, 120. 130 
chronic aural catarrh, 83, 90. 104 
excision of, 108, 130 
hook. Ill 
incudo-stapedial articulation. 106. 

113 
vibrator, 104 
Osteomata, nasal cavities. 277 
Othematoma of auricle. 51 
Otitis, externa, acuta, 58 
chronica. 58 
circumscripta, 60 
diffusa, 58 
parasitica. 62 
media, acuta. 73 

from nasal douche. 73 
paracentesis. 77 
chronica, S3, 90 
purulenta, acuta, 78 
chronica, 116 
Otomycosis, 62 
Otorrhcea, chronic, 116 
Otoscope, massage, 18, 98 
Overtreatment, 87 
Ozena, 268 

cause of eye diseases. 311 

Pachvdermia larvnais. 503 
Palate, Plates II, IV. V 
Panas, 310 
Panophthalmitis. 311 
Panotitis, 184 
Papillomata, of larynx. 502 

of nasal cavities. 276 
Paquin, Paul, 497 
Paracentesis membranae tvmpani. 77. 

88 
Paracusis, duplicata. 188 

Willisii, 188 
Paresthesia, of larynx, 487 

pharynx, 436 
Paralvsis. of auditorv nerve. 191 

facial nerve, 121. 134. 177 

larynx, 489, 491 

pharynx, 437 
Parasitic otitis externa. 62 
Paresis of auditory nerve. 191 

facial nerve. 134. 191 
Park, Roswell, 512 
Parosmia. 286 
Peiper. 238 

Pemphigus of auricle, 52 
Perforation of membrana tvmpani. 73. 
78. 116. 118 

of nasal septum, 227. 292 
Perichondritis of auricle. 50 
Periosteum separator. 159 
Pharyngeal tonsil, 319. 324 



Pharyngitis, acute. 335 
effect on ear, 33 Li 
treatment, 337 
chronic, 341 
follicular, 349 
herpetica, 352 
in measles, 347 
membranous, simple. 352 
rheumatic, 342, 344 ' 
scarlatina, 348 
small-pox, 349 
syphilitic, 424 
tubercular, 420 
Pharyngomycosis. 414 
Pharynx, 335, Plates II. V 
acute inflammation. 335 
burns and scalds, 437 
diphtheria. 355 

effects of nasal disease on, 350 
foreign bodies, 438 
herpes, 352 

malignant disease. 430 
morbid growths, 416 
innocent growths, 416 
fibroma, 416 
papilloma. 416 
malignant growths, cancer, 430 
carcinoma, 430 
epithelioma. 430 
sarcoma. 323 
neuroses, 435 
of motion, 436 
of sensation. 435 
parasitic disease. 414 
uvula, bifid and double, 418 
uvula, inflammation. 416 
malformations, 418 
Phlebitis of sinuses, 147 
Phlegmonous inflammation of antrum 

of Highmore, 300 
Phlyctenular disease from rhinitis. 

310, 311 
Phonograph, 101 

Photophobia from nasal disease. 312 
Politzer. Adam, 33, 34, 41. 92, 184, 192 
Politzerization. 41 
Pollen as a cause of hav fever. 233 
Polypi, aural. 120. 127" 
cystic, nasal. 275 
mucous, of larynx, 505 
nasal. 274 

naso-pharvnx. 322. 323 
Pomeroy, 0*. D.. 108 
Porcher. W. P., 488 
Porter. 459 

Post-nasal catarrh. 317 
Powder-blowers, 60. 122. 429 
Powders, antiseptic. SO, 81, 122-124. 
Appendix 



INDEX. 



Preparation of patients and instru- 
ments for operations, 156- 
158 
Prognosis in ear diseases, 8 
Prophylaxis of acute rhinitis, 225 
Prudden, 355 
Prussak's space, 68 
Pseudomembranous croup, 458 
Psvchic influence in hay fever, 230 
Puech, 311 

Pulling the ears. 51, 67 
Pumps, air-, 36-40 
Purulent otitis media, acute, 78 
chronic, 116 

pyaemia in, 121, 140 
Pynchon, Edwin, 413 

Quain, 248 

Quine, William E., 396 
Quinquaud, 236 
Quinsy, 399 

Ramsev, 310 
Randall, 51 
Ranke, 461 
Ray, J. M., 518 
Records of cases, 3, 28 
Reflex affections of the eye and nose, 
312 

nose, 229, 231, 259, 277, 291, 312 

voice, 490 
Reflexes, laryngeal, 490 

ocular, 312 

sexual, 490 
Regulator, air-, 30 
Reichat, 449 
Related diseases of the eye and nose, 

307 
Relative frequency of diseases, 3, 7, 8 
Resection of drum-head, 107, 108, 110 
Reservoirs, air-, 36-41 
Retractors for mastoid operations, 160 
Retropharyngeal abscess, 152, 182. 433, 

Plate V 
Reynolds, A. R., 390 
Rheumatic sore throat, 342, 344, 456 
Rheumatism and gout, effects on ear, 

91 
Rhinitis, acuta, 223 
clothing, 225 
complications, 225 

atrophica, 268 

hypertrophica, 255 

simple chronic, 226 
Rhinoliths. 278 
Rhinoscopic instruments, 20o 
Rhinoscopv, 207 
Rhodes, J. E., 465 
Rice, 482 
Richards, H., 45 



Richey, S. O., 100 

Rhine's test for hearing, 25 

Ritter, M. M., 393 

Robinson, Beverly, 254 

Robison, John A., 397 

Roe, John O., 253, 479 

Roof of tympanum, 113, 150, Figs. 109, 

110 
Roosa, D. B. St. J., 66, 311 
Rosenmiiller's fossa, Plate II 
Rosenthal, Edwin, 381 
Roux, 355, 375, 376 
Roy. 238 
Ruedo, 138 

Rumbold. Thomas F., 310, 326 
Frank, 151 

Sajous, Charles E. de M., 253, 341, 422, 

429, 479 
Salpingitis, 69 
Sarcoma, of larynx, 512 

of nose, 278 
Saw in nasal deformities, 268 
Scarlatina, pharynx in, 348 
Schadle, J. E., 329 
Scheibe, 151 

Scheppegrell. William, 268, 296 
Schrotter, 485, 501 
Schwabach's test for hearing, 23 
Schwalbe, 431 
Schwartze, 162, 184, 192 
Schweinitz, G. E. de, 308 
Sclerosis, of mastoid, 151 

middle ear, 90, 104 
Scroll-ear, 54 

Sea-bathing, effect on ear, 73 
Seiler. Carl, 254 

Seiss, Ralph W., 252, 266. 267, 310 
Semon, 326 

Septum, nasi, diseases and deformities, 
255, 287, 294, 297 

knife, 268 

perforation, 227, 292 
Sequels of middle-ear suppuration, 127 
Sequestra from ear, 139, 142 
Serous otitis media, 83 
Sex, influence, in disease, 3, 7, 490 
Sexton, Samuel, 114, 137 
Sexual anomalies, effects on voice, 490 
Sherrington, 238 

Shrapnell's membrane, 21, Plate I 
Shurley, E. L., 252, 479, 480 
Sinus, inferior petrosal, 150 

lateral, 140. 150, 165, 166, 169, 170, 
173 
Sinuses, accessory, of nose, 297 

ethmoid. 301 

frontal, 303 

maxillary, 297 

sphenoid, 303 



IXDEX. 



553 



Sinus-phlebitis and sinus-thrombosis, 

147 
Small-pox, throat in, 349 
Smell, sense of. 286 
Smith. A. H.. 07 

J. Lewis, 358, 3G8, 371 
Snare, ear, 127 
Sokolowski, 405 
Solutions, antiseptic. Appendix 
Sore throat, acute, 335 

chronic, 341 

clergymen's, 349 

common membranous, 352 

folliculous. 340 

gouty, 342. 344 

granular. 349 

measles, 347 

rheumatic, 342, 344 

scarlet fever, 348 

small-pox, 349 
Spasm of larynx, 454 

of pharynx, 436 
Spasmodic croup. 486 
Spear, E. D., 186 
Specula, aural, 17, 18 

nasal, 206 

Siegle's pneumatic, 98 
Speech in testing the hearing, 27 
Sphenoid sinuses, 303 

diseases of. effect on eye, 303 

tumors. 303 . 
Sphenopalatine ganglion, 231 
Sprays, 215 

for ear. 34. 35. 88 
Spurious croup. 452 
Stacke's operation, 172 
Stapes, 91, 105, 139, 141. 167 

mobilization of, 110, 114 

removal of. 115 
Statistics, 3, 391 
Stenosis of Eustachian tube, 35. 72 

of larvnx, 484, 498. 500. 501. 509 

of nasal cavities, 224, 245, 259. 274. 
319, 326 
Sterilizing instruments, 158, 327 
Strabismus from nasal disease, 312 
Stridulous larvngitis, 454, 461 
Strueh, 387 

Subjective sounds, 74, 86, 92. 133. 188 
Synechia of nasal cavities, 255, 313 
Syphilis, of auricle. 52 

internal ear, 186 

larynx, 498 

nasal cavities, 280 

pharynx, 424 
Syphilitic stenosis of larynx, 500 
Syringes, 58 

Tables, statistical. 4. 5. 6. 11. 391 
Tablets, corvza, 338 



Tablets, cough-, 339 

throat-, 339 
Talbot, E. S., 52 
Tamponing nares. 273 
Taylor, James L., 387 
Tegmen. mastoideum, 150, 170, Figs. 
109. 110 
tvmpani. xl3, 150. Figs. 109, 110 
Temporal bone, 140, 141, 165-170, Figs. 
109, 110 
caries of, 138 
Tensor tvmpani, 70 
tendon of, 68 
tenotomy of, 108 
Tests of hearing, 21-27 
acoumeter, 26, 27 
Bing*s test, 25 
expressions for. 22 
Galton's whistle, 26 
Gelle's test. 20 
Rhine's test, 25 
speech, 27 
tuning-forks, automatic, 23 

Hartmann's, 24 
watch, 22 

Weber's method, 25 
whispers. 27 
Thomas. H. M.. 214, 415 
Thorner. Max. 335. 340, *47. 451 
Throat-tablets, 339 
Thrombosis of sinuses, 147 

and jugulars, 148 
Tinnitus aurium, 74, 86. 92, 133, 188 
Toeplitz. Max. 138, 187, 415, 513 
Tongue-depressor, 207 
Tonsil, calculi, 415 

hypertrophy, of oral, 405 

pharyngeal, 324 
mvcosis. 414 
of Luschka, 319, 324 
pharyngeal. 319, 324 
syphilis. 424 
tuberculosis. 420 
Tonsillitis, acute, 399 

treatment, 402 
Tonsillotome, 409 
Tonsillotomy, 408 
Tonsils, acute inflammation, 399 
chronic inflammation, 405 

adenoids in vault of pharynx. 324 
aural symptoms from, 326 
treatment. 407 
anaesthetics, 408 
haemorrhage from tonsillotomv, 

411 
hot snare, 413 
tonsillotome, 409 
tonsillotomy, 408 
Wright's electric amvgdalotome 
413 



554 



INDEX. 



Tonsils, hypertrophied, 405 

lacunae of, 407 

large, 405 

parasites in, 414 

varieties of inflammation, 399 
Toynbee's auscultation-tube, 45, 46 
Tracheotomy, 470 

choice of operation, 471 

high operation, 471 

low operation, 473 
Trachoma from nasal disease, 311 

of vocal cords, 482 
Transfixion needles in nasal hypertro- 
phies, 267, Plate V 
Trelat, 420 

Tuberculin in tuberculosis, 423, 497 
Tuberculocidin in tuberculosis, 423 
Tuberculosis, effect, on ear, 119 
larynx, 494 
nasal cavities, 280 
pharynx, 420 
Tumors of antrum of Highmore, 300 
auricle, 51 
larynx, 502 

nasal cavities, 274, 322, 323 
pharynx, 416 
Tuning-fork, automatic, 23 
Turbinated bodies, 255-258, 290 ?91 

297-302, Plate II 
Turk, F. B., 220 
Turnbull, 200 

Tympanic cavity, 113, Figs. 109 110 
floor of, 113 

inner wall, Figs. 109, 110 
mucous membrane. 121 
outer wall, 70, 106 
Tympanum. See Tympanic cavity 
Tyrrell, Shawe, 238 

Umbo of membrana tympani, Plate I 

Urbantschitsch, 198 

Uterine reflex neuroses of larynx 489 

490 
Uvula, Plates II, IV, V 
Uvula, bifid and double, 418 
Uvulitis, 416 

Valsalva's inflation, 101 



3>v 



C 



\ 



Van der Poel, 330 

Vapors, use of, in ear, 37, 38 

Variola, pharynx in, 349 

Vegetable parasites in ear, 62 

Veilon, A., 399 

Velum palati, Plates II, IV V 

Vertigo, 93, 144, 145, 148,' 183 185 

186, 192, 312 
Vestibule, 165, 169 
Vibrator, ossicle, 104 
Virchow, Rudolph, 133, 358, 405, 503 
Visual field, contraction from nasal 

disease, 313 
Vocal cords, granulations of, 482 

trachoma, 482 
Voice in laryngeal diseases, 452 476 
477, 502, 508 
m nasal diseases, 259, 326 
in sexual abnormalities, 490 
Voice, reflex affections of, 490 
"Vulpius, 153 

Wagner, Clinton, 224 

Walls, F. X., 393 

Watch-test for hearing, 22 

Wax in ear, 56 

Weber's test for hearing, 25 

Webster, 184 

Welch, W. H., 355, 390 
Whisper-test for hearing, 27 
Whistle, Galton's, 26 
Whi taker, H. W., 415 
White, J. A., 249 
Wilde's incision, 155 
Wile, William C, 369 
Winters, 386 
Witzel, 331 

Wolfenden, Norris, 405, 497 
Wright, Jonathan, 252, 293, 413 
Wurdemami, H. V., 97 
Wyman, Morrill, 232 

Yersin, 357 

Zaufal, 147 

Ziemssen, 475, 477, 509 

Zuckerkandl, 287 



U 



